Journal of Chiropractic Humanities: Volume 16, Issue 1, (December 2009)

The Journal of Chiropractic Humanities (ISSN 1556-3499) is a peer-reviewed journal devoted to providing a forum for the chiropractic profession to disseminate information dedicated to chiropractic humanities. The primary purpose of the Journal of Chiropractic Humanities is to foster scholarly debate and interaction within the chiropractic profession regarding the humanities, which includes history, philosophy, linguistics, literature, jurisprudence, ethics, theory, sociology, comparative religions, and aspects of social sciences that address historical or philosophical approaches. The journal’s objective is to fulfill this purpose through careful editorial review and publication of expert work, by creating legitimate dialogue in a field where a diversity of opinion exists, and by providing a professional forum for interaction of these views. The journal is currently indexed in Cumulative Index to Nursing and Allied Health Literature (CINAHL), Manual Alternative and Natural Therapy Index System (MANTIS), and the Index to Chiropractic Literature (ICL).

Editorial Offices: National University of Health Sciences 200 E. Roosevelt Road Lombard, Illinois 60148 [email protected]

Editor: Claire Johnson, MSEd, DC

Associate Editor: Bart Green, MSEd, DC

Editorial Board Members: Alana Callender, MS, LCP, EEd Ron Carter, DC, MA, PhD Keith Charlton, DC, MS Ashley Cleveland, DC, MS

Chris Good, DC, MAEd Stuart Kinsinger, DC Doug Lawson, DC, MSEd Brian McAulay, DC, PhD Stephen Perle, DC, MS

Reed Phillips, DC, MSCM, PhD Keith Simpson, DC, PhD Robert Ward, DC Keith Wells, DC, MA

The Journal of Chiropractic Humanities (ISSN 1556-3499) is published annually.

General Information: www.nuhs.edu; www.JournalChiroHumanities.com

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TABLE OF CONTENTS

Volume 17, Issue 1, December 2010

Editorial 1

Reflecting on 115 years: The chiropractic profession’s philosophical path Claire Johnson

Original Article 6

Constructing a philosophy of chiropractic I: An Integral map of the territory Simon A. Senzon

Commentaries 22 Historical overview and update on subluxation theories Howard Vernon 33 The great subluxation debate: A centrist’s perspective Christopher J. Good 40 Implications and limitations of appropriateness studies for chiropractic James M. Whedon, Matthew A. Davis, and Reed B. Phillips Original Article 47 The Fountain Head Chiropractic Hospital: The dream that almost came true Barclay W. Bakkum and Delores Bakkum Nolan

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Journal of Chiropractic Humanities (2010) 17, 1–5

Editorial

Reflecting on 115 years: the chiropractic profession's philosophical path Claire Johnson DC, MSEd⁎ Professor, National University of Health Sciences, Lombard, IL Editor, Journal of Chiropractic Humanities Key indexing terms: Chiropractic; History; Philosophy

Abstract The chiropractic profession struggled with survival and identity in its first decades. In addition to internal struggles between chiropractic leaders and colleges, much of our profession's formative years were stamped with reactions to persecution from external forces. The argument that chiropractic should be recognized as a distinct profession, and the rhetoric that this medicolegal strategy included, helped to develop chiropractic identity during this period of persecution in the early 20th century. This article questions if the chiropractic profession is mature and wise enough to be comfortable in being proud of its past but still capable of continued philosophical growth. © 2010 National University of Health Sciences.

Introduction It was only 15 years ago that we celebrated a monumental occasion, the chiropractic profession's 100th anniversary (Fig 1). There were some who attended the centennial celebrations who had thought at one time that the profession would not survive long enough to reach the century mark. Yet in spite of many hardships, some brave souls fought diligently and helped us accomplish our 100-year milestone. However, as with many achievements, once the event has passed, we often forget about what efforts need to be continued. Instead, we go back to the issues of the day. This ⁎ 200 E. Roosevelt Rd., Lombard, IL 60148. E-mail address: [email protected].

makes me ask the following questions: Have we demonstrated professional and intellectual growth? Are we mature and wise enough to be comfortable in being proud of our past and at the same time capable of philosophical growth? These questions may be difficult to answer because there has not been a concerted effort to study our progress; however, I think that they are worth pondering. Chiropractic has been disparaged, sometimes correctly but sometimes incorrectly, for not being self-critical enough or for not developing sound scientific and philosophical constructs on which to build a profession. 1,2 In addition, there has been infighting in the profession between those who wish to be grounded in science and philosophy and those who espouse that a dogmatic approach (under the guise of “philosophy”) will keep our profession strong and independent. Where do we in the

1556-3499/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.echu.2010.11.001

2

C. Johnson

Fig 1. Badge from the chiropractic centennial celebrations held in 1995.

chiropractic profession get our silliness from when it comes to our identity? The original identity of the chiropractic profession was formed initially by our founder, Daniel David Palmer. Those DD Palmer taught, such as John Fitz Alan Howard, Solon Langworthy, and Oakley Smith, continued to develop chiropractic concepts and made additions and modifications to what they were taught; but they did so in isolation, not collaboration (Fig 2). Additional leaders would follow, such as Bartlett Joshua Palmer, Tullius de Florence Ratledge, and Willard Carver, who made changes in their approaches

Fig 2.

to educational programs and how chiropractors were perceived as healers (Fig 3). Although we had strong leaders, they were not united. Instead of cooperation, there was competition and infighting between factions. Many of these actions were posturing due to the proprietary nature of the chiropractic colleges in an effort to enroll students. These divisions created discontinuity and disruption in the development of the art, science, and philosophy of chiropractic. When chiropractic groups did work together, it was typically when chiropractic was being attacked. 3 The medical and legal professions were in positions of power and cultural authority and provided external pressure that shaped the chiropractic profession. In the United States, medical licensing laws forbade the practice of medicine without a license. Medicine was dominated by allopathic “regulars” who, through the organization of the American Medical Association, developed a code of ethics that banned practice and association with irregulars. 4-6 At the turn of the century, chiropractors were one of the primary targeted groups of “irregulars” that the medical profession was addressing in the legal arena (Fig 4). Such external pressures had wide-ranging effects on the chiropractic profession. The first successful legal defense of chiropractic was the Morikubo trial (1907) in which Shegataro Morikubo, DC, was arrested for practicing medicine without a license 7 (Fig 5). The legal defense, led by Tom Morris, set out to prove that one who was practicing chiropractic had a distinct art, science, and philosophy in an effort to distinguish this practice from medicine (Fig 6). The legal defense hoped that by proving that chiropractic was not

Oakley G Smith, John Fitz Alan Howard, and Solon M Langworthy.

Chiropractic profession's philosophical path

Fig 3.

3

Bartlett Joshua Palmer, Tullius de Florence Ratledge, and Willard Carver.

allopathy, the laws of the time would not apply to chiropractors. Later, in 1911, the Universal Chiropractors Association (UCA) recognized the need to standardize terminology for the purpose of legal terms and set out “… to decide upon what was and what was not Chiropractic, what the U.C.A. could admit as Chiropractic and could defend” 8 (Fig 7). At this same meeting, a report given on the standardization of chiropractic recognized that the legal defense counsel of the UCA (Morris and Hartwell) were defining chiropractic, “Morris & Hartwell … are standardizing Chiropractic. They are telling the local attorney what Chiropractic really is.”8 Chiropractic terminology, concepts, and definitions were crafted and refined for the courtroom, not necessarily from clinical or laboratory research. Thus,

Fig 4. Cover of The Chiropractor announcing DD Palmer's jailing for practicing chiropractic. The cover states “Dr. D.D. Palmer: Martyr to His Science, Chiropractic.”

Fig 5. Daniel David Palmer adjusting his former student and 1906 Palmer School of Chiropractic graduate, Shegataro Morikubo, DC.

4

Fig 6. Thomas D Morris, who practiced with his law partner Fred H Hartwell, was the first lawyer to successfully defend chiropractic in the courtroom.

much of the terminology that we consider as a part of chiropractic identity today was not generated from a proactive development from within our profession but from a reactive set of legal defense arguments. Much of our identity did not necessarily come from internal formative developmental efforts, but instead from reactions to external pressures.

C. Johnson Success in a few of these legal trials gave early chiropractors hope and courage, but may also have given them overconfidence that ingrained some of these legal defense concepts into our culture and philosophical constructs. They also created a chink in our armor. The very arguments that seemed to save the profession in the early and mid 1900s now may be some of the greatest weaknesses that we face as a profession. Many of the current concerns, including diagnosis (vs analysis), manipulation (vs adjustment), treatment (vs care), disease (vs dis-ease), doctor of chiropractic (vs chiropractor), and scope of practice issues, would likely not be in existence if the profession had not been required to fight these medicolegal battles. It would have been interesting to see how we would have developed if we were left to develop on our own, but we will never know. Understanding some of the origins of the difficulties we face today, we must decide how we should move forward. Do we need to hold on to concepts that served us well at the time but hinder us now? Should we ignore our past and stride forward without looking back? Choosing the latter path may detach us from our roots, leaving us ungrounded and unable to learn from our past mistakes. Should we hold tightly to past dogma and ignore the current scientific facts before us? Choosing the path of holding onto philosophy that is not supported by science turns us into fanatics on the fringe, a religious cult instead of a profession. I feel that it is important to recognize the richness of our past and honor those who have come before us, but it is also important not to overinterpret their works or create gods of them. They were just people doing their job at that time. They most likely did not intend to have

Fig. 7. Universal Chiropractors Association Convention circa 1910. The UCA was founded in 1906 to legally protect its dues-paying members.

Chiropractic profession's philosophical path their actions and words be written in stone. Instead, they may have expected the future generations to think for themselves. Daniel David Palmer seemed to be comfortable with allowing the chiropractic profession to evolve, even if he wanted it to be on his terms. In the 1910 Chiropractor's Adjuster, Palmer wrote, “As a means of relieving suffering and disease, Allopathy, Homeopathy, Osteopathy, and now Chiropractic, have each in turn, improved upon its predecessor. But, as soon as the human mind is capable of absorbing a still more advanced method and human aspiration demands it, it will be forthcoming and I hope to be the medium thru [sic] which it will be delivered to the denizens of the earth.”9 Maybe we should allow our profession to grow, lest we become extinct like other healing professions before us.10 As a profession, we continue to struggle with empowering ourselves to question and think for ourselves while at the same time holding on to the spirit and identity of chiropractic. On one hand, some may feel that if we question the basis of chiropractic, we may lose our identity. On the other hand, some may feel that if we recognize our historical origins, we betray current concepts in chiropractic science and rational thought. As we grapple with these concepts, there is hope that there may be a common path that we can walk. As Ian Coulter, PhD eloquently states, “… philosophy is an activity and not some body of doctrine.”11 He also states that philosophy is critical, problem oriented, and controversial. 11 Instead of memorizing rhetoric, we need to think critically and challenge the chiropractic profession to continue to grow in a meaningful direction.

Conclusion Part of our journey on the professional path to enlightenment includes wrestling with what we think is true and what is the truth. There may be a path in which we can be proud of our past and learn from our mistakes while at the same time not letting past myths and legends destroy living in the present. I feel that after 115 years, we have the maturity and wisdom to embrace both. The question remains if we will have the courage to do so.

5

Funding sources and potential conflicts of interest No funding was received for this article. Claire Johnson, DC, MSEd, is the editor of the Journal of Manipulative and Physiological Therapeutics, Journal of Chiropractic Medicine, and Journal of Chiropractic Humanities; a full-time professor at the National University of Health Sciences; peer review chair for the Association of Chiropractic Colleges; a board member of NCMIC; and a member of the American Chiropractic Association, American Chiropractic Board of Sports Physicians, International Chiropractors Association, Association for the History of Chiropractic, Counsel of Science Editors, American Public Health Association, Committee on Publication Ethics, World Association of Medical Editors, American Medical Writers Association, and American Educational Research Association.

References 1. Keating Jr JC, Green BN, Johnson CD. “Research” and “science” in the first half of the chiropractic century. J Manipulative Physiol Ther 1995;18(6):357-78. 2. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008;35(5):544-62. 3. Peterson D, Wiese G. Chiropractic: an illustrated history. St Louis: Mosby; 1995. 4. Gevitz N. The chiropractors and the AMA: reflections on the history of the consultation clause. Perspect Biol Med 1989;32: 281-99. 5. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Arch Intern Med 1998;158:2215-24. 6. Johnson C. Keeping a critical eye on chiropractic. J Manipulative Physiol Ther 2008;31(8):559-61. 7. Rehm WS. Legally defensible: chiropractic in the courtroom and after, 1907. Chiropr Hist 1986;6:51-5. 8. Minutes. Sixth annual convention of the Universal Chiropractic Association. August 28–September 2, Davenport, Iowa; 1911. 9. Palmer DD. Textbook of the science, art, and philosophy of chiropractic: the chiropractor' adjuster. Portland (Ore): Portland Printing House; 1910. 10. Green BN. Gloom or boom for chiropractic in its second century? A comparison of the demise of alternative healing professions. Chiropr Hist 1994;14(2):22-9. 11. Coulter ID. Chiropractic: a philosophy for alternative health care. Woburn, MA: Elsevier Health Sciences; 1999.

Journal of Chiropractic Humanities (2010) 17, 6–21

Original article

Constructing a philosophy of chiropractic I: an Integral map of the territory Simon A. Senzon MA, DC⁎ Adjunct Assistant Professor, Department of Integral Theory, John F. Kennedy University, Pleasant Hill, CA 94523 Received 21 September 2010; received in revised form 26 October 2010; accepted 30 October 2010 Key indexing terms: Philosophy; Chiropractic; Model, Theoretical; Methods

Abstract Objective: The purpose of this article is to establish a metatheoretical framework for constructing a philosophy of chiropractic by using Integral Theory and Integral Methodological Pluralism. This is the first in a series of 3 articles. Discussion: The philosophy of chiropractic has not thrived as a philosophic discipline for multiple reasons. Most notably, these include disparate personal and cultural worldviews within the profession, a historical approach to chiropractic's roots, and an undeveloped framework for exploring philosophy from multiple perspectives. A framework is suggested to bridge divides and create a groundwork for a philosophical discipline using Integral Methodological Pluralism developed from Integral Theory. A review of the literature on the philosophy of chiropractic is mapped according to the 8 primordial perspectives of Integral Methodological Pluralism. It is argued that this approach to constructing a philosophy of chiropractic will bridge the historical divides and ensure a deep holism by pluralistically including every known approach to knowledge acquisition. Conclusion: Integral Methodological Pluralism is a viable way to begin constructing a philosophy of chiropractic for the 21st century. © 2010 National University of Health Sciences.

Introduction The philosophy of chiropractic has been discussed and debated in the chiropractic profession for more than 100 years. Despite 2 academic and political consensus statements on philosophy, 1,2 little progress has been ⁎ Adjunct Assistant Professor, Department of Integral Theory, John F. Kennedy University, 100 Ellinwood Way, Pleasant Hill, CA 94523. Tel.: +1 925 669 3141. E-mail address: [email protected].

made toward actionable steps in educational standards, curriculum development, continuing education standards, licensing requirements, or the creation of an explicit discipline of philosophy in chiropractic. 3 The literature on philosophy has grown in the last 2 decades, 3-22 although it has not always met the highest levels of scholastic rigor.3 Part of the problem in developing a scholarly debate and discipline around the philosophy of chiropractic has been political, legal, social, and economic realities that have historically influenced the philosophy development, 13,23-25 as well

1556-3499/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.echu.2010.10.002

Constructing a philosophy of chiropractic as the political agenda of various factions in the profession. 17,19 Other limiting factors include personal worldviews and experiences, 7,26,27 cultural perspectives,15,24,28-30 interpretive frames of reference in regard to data collection, 31-33 research methodologies, 34,35 and clinical approaches. 36,37 Ideally, philosophy guides clinical choices, professional development, research foci, political initiatives, policy, doctor-patient interactions, ethics, and education. A sound philosophy should also act as a guide for personal development of the doctor. In the case of a profession focused on health, wellness, and optimal human function, the philosophy should guide the patient's personal development as well. The profession's founders developed their philosophical positions from unique social, legal, cultural, and personal contexts. 23,24,28,38-45 These early philosophical approaches created category errors between internal, subjective psychospiritual development and objective, external healing capacities in tandem with universal first principles and individualized metaphors for healing. 10,46-48 This led to testable hypotheses becoming mixed up with philosophical explanations, and body/mind health described in metaphysical and religious terminology. 15,19 , 46-49 For example, DD Palmer, the founder of chiropractic, and BJ Palmer, his son and president of the first chiropractic school for almost 60 years, both equated the body's ability to self-heal with the soul and a universal organizing principle of all matter with God.44,47 The original philosophy they started has its roots in 19th century American metaphysical culture, with roots that go back to a long history of Western esotericism. 15,24,29,30,50,51 Sorting through these many tangled issues has been debated in the chiropractic profession since its inception and publicly in the peer-reviewed literature for about the last 20 years. The Palmers' also attempted to explain principles of energy healing associated with chiropractic in scientific language 50 to 100 years before energy medicine developed its own scientific lexicon and research protocols. 52-55 These inherent challenges created an internal tension whereby chiropractors were forced to “take sides” against each other while fighting for professional and legal recognition as well as cultural authority in health care and the greater society. Since the start, chiropractors struggled to survive and disagreed among themselves how best to deal with these philosophical beginnings. That legacy left a fragmented profession without a philosophic discipline. The roots in 19th century metaphysical systems and healing traditions prove well documented 15,24,28,29,44,56

7 and are often described in the early chapters of modern textbooks 37,56-60 ; but no attempts to integrate or come to terms with these early approaches have resulted in the development of a discipline of philosophy for the chiropractic profession. 3,12,14,37,61 The philosophical underpinnings and arguments are often described in part as “recycled” ideas from the history of ideas,14,62,63 important primarily for legal purposes 23,41,45 or relegated to a century-old simplistic polarity between “straights” and “mixers.”28 ,64-67 This fragmentation has led to a recent decision by a chiropractic professional governing body, the General Chiropractic Council, 68 to dismiss chiropractic's most “defining clinical principle,” 69 (p37) the vertebral subluxation (VS), and then, after much protest, partly change its stance. 70 Vertebral subluxation, acknowledged by most national and international governing bodies, is now referred to by the General Chiropractic Council as a historical artifact. 71 Although this latest drama in the historical debate is focused on clinical nomenclature, VS, and research methodologies, it nonetheless relates to philosophy. Several researchers have stressed the need for alternative research paradigms to truly capture the nature of the chiropractic encounter and alternative methods in general. 5,7,10,22,33,35,55,67,72 Vertebral subluxation has remained central to the wide-ranging philosophical approaches within the profession and rarely differentiated from those approaches. Without a distinction between clinical encounters, research, and chiropractic's traditional reason for being (VS) from theories and philosophy, this type of confusion and its resulting legal and political consequences prove inevitable. If philosophy in chiropractic is to develop into a discipline, it needs to transcend and include all elements of the profession from scientifically testable theories, which range from VS to doctor-patient interactions; ethical, legal, and political questions; and all possible ramifications of the chiropractic encounter. This latter area of study would include biopsychosocial and spiritual health and well-being. A philosophy of chiropractic should be able to include science, art (as in chiropractic as a healing art), and ethics or morals. It is in this spirit that I approach the topic in this article. This article proposes the use of Integral Theory (IT) and its Integral Methodological Pluralism (IMP) to heal the fractures in the chiropractic profession and develop a discipline of philosophy. Integral Theory and IMP can be used to unite all approaches to date in regard to philosophy and lay the groundwork for a comprehensive approach to philosophy. Integral

8 Theory does this by offering an orienting framework that can integrate 4 domains of truth: subjective, objective, intersubjective, and interobjective. 73 Such a framework opens the way for a meaningful discussion around the central debates in the philosophy of chiropractic such as the relationship between science and philosophy, the importance of subjective perceptions of health and well-being, the doctor-patient relationship, belief systems, and the impact of social and cultural domains on the profession and the philosophy. Integral Theory also offers a way to explore the more complicated subjects of innate intelligence as a somatobiological and psychospiritual metaphor; the social and cultural history of philosophy and how it relates to chiropractic's emergence; the relationship between quantitative and qualitative research; and the many worldviews and perspectives individual chiropractors, educators, researchers, and philosophers bring to the profession. Integral Methodological Pluralism is a recent development of IT. 73 Integral Methodological Pluralism combines 8 methodological approaches to knowledge acquisition. Combined, these 8 methods include every known domain of knowledge humans have claimed to know. By applying each of these 8 methodologies to the philosophy of chiropractic, a comprehensive pluralism is ensured, whereby no domain of knowledge is left out. The current article defines these methodologies and then examines where they have already been addressed in the literature on philosophy in chiropractic. Some of these methodologies such as empiricism and systems have often been overemphasized and explored in great detail. Other domains such as autopoiesis or the organism's ability to create its own parts and “know” itself from its environment have not been addressed in detail, beyond the biological definitions of innate intelligence and a few specific references in the literature. The methodologies least addressed in the literature are phenomenology, structuralism, ethnomethodology, and cultural anthropology. It is these domains that will be addressed in the second and third articles of this series. In the first issue of Philosophical Constructs for the Chiropractic Profession, the precursor to the Journal of Chiropractic Humanities, Joseph Donahue suggested that we nurture philosophers in the profession who are well read in a variety of disciplines and educated in philosophy to act as the profession's soul by stirring debate and emotion. 15,74 This sentiment is widespread, as is the agreement that a discipline of philosophy in chiropractic is necessary. 1,2,3,5,11,12,17,19,37,61 To embrace the wealth of diverse perspectives, include

S. A. Senzon original philosophic premises, adhere to the history of ideas, acknowledge social and cultural forces shaping the profession, and honor the scientific validity claims around clinical entities, a broad framework is required. Critiques and perspectives on healing chiropractic's divisions Many approaches attempt to deal with the philosophical challenges at the center of chiropractic's history: to emphasize the clinical encounter and doctorpatient interaction as central 5,7,13,75 ; to reconcile the philosophical approaches by expanding research methodologies to include whole systems 34,35 ; to dismiss all spiritual jargon from the philosophy 9,12,49,76,77 ; to expand on the traditional philosophical premises 6,15,16,20,78 ; to link the philosophical premises to complexity and systems theory 46,79-81 ; to relate it to a hierarchy of values or worldviews and to the highest levels of human function and spiritual development 8,15,26,27,44,46,82 ; and to embrace the wider root metaphors underlying the philosophical premises such as vitalism, holism, naturalism, therapeutic conservatism, and critical rationalism. 10,60,80 This latter approach, in particular, has garnered wide support within the profession. 83,84 McAulay 3 describes the internal debate within the profession along the polemic of 2 methodological approaches, which have not been acknowledged in the wider discussion. These include the “dismissivist approach,” which dismisses the basic premises of the early philosophical models, and the “authoritarian approach,” which accepts those models as the basis of chiropractic's philosophical underpinnings. McAulay called for a third approach, the “critical approach,” which uses basic components of discipline and argument building to achieve consensus and rigor. He uses examples from the literature to make a strong case for the use of critical thinking in developing a discipline of philosophy within chiropractic. Such a method would include 8 core standards of scholastic rigor: clarity, accuracy, precision, relevance, depth, breadth, logical consistency, and intellectual traits. Furthermore, he identifies core intellectual traits such as “intellectual humility, intellectual courage, intellectual integrity, intellectual perseverance, intellectual simplicity, intellectual autonomy, and confidence in reason.”3(p24) McAulay's critical approach is essential to the development of a discipline because it ensures a move forward, “in thinking and knowledge acquisition,”3(p18) and suggests a way to rigorously broaden the dismissivist and authoritarian approaches. It is

Constructing a philosophy of chiropractic certainly an approach worth emulating in terms of moving forward. Yet, as a “critical approach,” it really only represents one methodology, albeit a very important one. One methodology is not enough for a comprehensive construction of a discipline of philosophy of chiropractic. An Integral approach According to IMP,85 there are at least 8 known methodologies for reproducible knowledge acquisition; and so, it is important to explore in this context. The 8 methodologies are empiricism, phenomenology, structuralism, autopoiesis theory, ethnomethodology/ cultural anthropology, hermeneutics, systems theory, and social autopoiesis theory. As will be discussed below, these 8 methodologies taken together represent the most comprehensive or integral ways humans have developed to acquire knowledge. Each one is nonreducible and thus represents a way of knowing that should be included in any philosophy that claims to be holistic. By applying IMP to constructing a philosophy of chiropractic, we can ensure that all perspectives on philosophy are being taken into account even when they disagree. This would expand on McAulay's 3 proposal by including his criteria of critical rationalism as the benchmark through which each methodology will be included. The current article will define IMP and suggest ways it can be applied to constructing a philosophy of chiropractic. This is the first in a series of 3 articles, which propose to build upon the literature and create an explicit framework for the construction of a discipline of philosophy in chiropractic. My goal is not to define what a philosophy of chiropractic is per se, but merely to set parameters allowing for a wide inclusion of ideas across diverse perspectives and philosophical insights. This article draws on IMP and its 8 methodological approaches to gaining knowledge. I propose IMP as a central organizing framework through which all discussions of philosophy in chiropractic can be viewed. The next article will build on some of these methods, examine chiropractic's emergence in the context of a history of philosophy, and consider ways it relates to the historical emergence of the “self.” Finally, a third article will elaborate on more of these methods and apply a developmental constructivist approach to the current arguments on philosophy. The goal of this article and the ensuing 2 articles is not to answer these questions as much as to create a map through which answers can be found and more complete questions can be asked.

9 Integral theory Integral Theory was originally developed by American philosopher Ken Wilber over the course of 25 books.86 Integral means “all inclusive,” and that is exactly what the theory does: it includes every aspect of reality humans have claimed to know. The primary method of inclusion is the use of the 3 major perspectives an individual can take to view reality, or the first-, second-, and third-person perspectives. The 4 quadrants were developed to capture the four irreducible dimensions that all organisms have. The 4 quadrants are broken down according to individual (upper quadrants)/collective (lower quadrants) and interior (left-hand quadrants)/exterior (right-hand quadrants). The upper left quadrant (UL) represents the firstperson perspective or “I.” This frames the view from within, the internal experience as well as an individual's personal worldview. The upper right quadrant (UR) refers to the view of the individual's body, an objective view, behavior, or “it.” Behavior includes the internal self-organizing capacity of an organism as well as its physical structures and actions. The lower left quadrant (LL) is the domain of collective interiors, or where 2 or more individuals can mutually resonate in shared and felt understanding, or “We.” This is the domain of culture and collective worldviews. The lower right quadrant (LR) is the domain of collective exteriors, or social realities, the shared interactive world space of 2 or more individuals in community, “its.” This is the domain of social and economic realities as well as the internal dynamics of social systems such as professions and clinics. Each quadrant has its own valid claim to truth: subjective truthfulness (UL), objective truth (UR), intersubjective justness (LL), and interobjective functional fit (LR). Integral Methodological Pluralism developed from IT (Fig 1). The quadrants can be understood as perspectives.

Fig 1.

Quadrants. Adapted from Wilber.87(p30)

10

S. A. Senzon

The quadrants represent the four views an individual can look through. In addition, anything can be looked at from all four quadrants (“quadrivium”) or from each quadrant individually (“quadrivia”). This is referred to as the “view through” or the “view from.”87 (p48) Thus any individual writing about the philosophy of chiropractic will look at the world through all four quadrants. Each individual views the world through these four lenses or “quadrant-perspectives.”87(p296) That same individual can write about philosophy of chiropractic as an object, from all four perspectives. Thus we can determine whether the philosophy addresses all four dimensions. In order to be complete and truly holistic, it must. Another example is the doctor-patient encounter; the doctor views the world through all four quadrants, containing an I-perspective, a We-perspective, an it-perspective, and an itsperspective. 87 The patient also has these four dimensions but can be viewed as an object and looked at from all four perspectives (a quadrivium of views about the patient); the doctor can inquire about the patient’s subjective feelings (UL), examine the patient’s body or actions (UR), and also inquire as to the patient’s cultural (LL) support, such as whether there are supportive people in the patient’s life they can talk to about living a healthy lifestyle, and social (LR) support systems such as family and work (Fig 2). Quadrants comprise 1 of the 5 elements of IT. The other 4 are levels, lines, states, and types. Levels refer to an increase in complexity in each quadrant. For example, in the LR quadrant, the chiropractic profession grew from one school and several students to several schools and to the third largest health care profession on the planet. In the UR quadrant, we can refer to increasing

complexity of biological organisms from cells to multicelled organisms, to organisms with primitive nervous systems, and to organisms with complex nervous systems. Lines refer to the variety of ways levels can be described in each quadrant. For example, in the LR quadrant, we can discuss the increasing complexity of legal structures, organizational structures, economic structures, etc. In the UL quadrant, we can describe an individual's increasing development of complexity through technical understanding, professionalism, moral compass, and empathic abilities. States refer to the transitory changes in each quadrant. For example, in the UR quadrant, we can discuss the state of health, illness, or wellness of the body. In the UL quadrant, we can discuss states of consciousness: alertness, drowsiness, melancholy, bliss, etc. Types refer to typologies in each quadrant. For example, in the LL quadrant, we can discuss the types of interactions between doctors and patients or between chiropractors. The signature phrase of IT is AQAL (pronounced ah-qwal); and it refers to All-quadrant, All-level, All-lines, All-types, and Allstates. For any approach to be integral, it must at least include all levels and all quadrants. The comprehensive approach that IT takes has proven versatile enough to be applied in several ways,88 throughout dozens of disciplines such as chiropractic,15,27,44,47,78 medicine,89,90 nursing,91,92 health care,93 consciousness studies,94,95 science,96 ecology,97 education,98 and politics,99 across disciplines such as integral psychology,100 which brings together the common elements from several approaches within psychology (an application that may be similar to what is required in chiropractic), and in transdisciplinary ways as in research,101 Integral Life Practice,102 and coaching.103 Integral Theory has developed into its own discipline, Integral Studies, which includes a Master's Degree,104 2 dedicated journals,105,106 a biannual scholarly conference,107 and an academic press.108 The most recent development of IT is referred to as IMP.85 Integral methodological pluralism

Fig 2.

Four quadrants with chiropractic examples.

Integral Methodological Pluralism is a postmetaphysical approach to knowledge using at least 8 of the most important methods developed for acquiring valid and reproducible knowledge (Fig 3). It is considered postmetaphysical because it acknowledges that all knowledge, even metaphysics, arises through methods of acquisition. Each method brings forth or discloses an aspect of reality. Thus, metaphysics itself is disclosed through such methods. The 8 methods are derived from dividing each quadrant into an inside and an outside,

Constructing a philosophy of chiropractic

phenomenology

autopoiesis (e.g. cognitive science)

structuralism

empiricism (e.g. neurophysiology)

subjective

objective

intersubjective

interobjective

hermeneutics

ethnomethodology

Fig 3.

social autopoiesis

systems theory

“8 Major Methodologies,” from Wilber.87(p52)

creating 8 views or perspectives (Fig 4). The views for the UL quadrant are introspection (inside) and structuralism (outside), those for the UR quadrant are brain (inside) and body (outside), those for the LR quadrant are social system (inside) and environment (outside), and those for the LL quadrant are culture (inside) and worldview (outside). 88 I argue that IMP (and IT) should be at the foundation of any future discussion of philosophy in chiropractic and central to the construction of a philosophy of chiropractic. The real importance of IMP is its inclusionary approach to knowledge through injunctions and practices. Guided by the pluralistic notion that everyone is partially right, it is thus ideal as an interdisciplinary and transdisciplinary approach to chiropractic. Without having content, IMP is a framework allowing for 8 verifiable truths, disclosed through 8 distinct methodologies, each nonreducible. For example, one cannot reduce the validity claim of an individual's interior experience (UL) to epiphenomenon of brain states (UR). Each has its own claim to truth. Integral Methodological Pluralism is a content-free map of reality. Few a priori assumptions about the world are required. This approach opens up many possibilities for a philosophy of chiropractic especially as Wilber posits a limited number of pregivens: Eros, or the inherent drive toward greater unities or wider identification; Agape, or an inherent tendency toward a wider embrace or more inclusion; a morphogenetic field of potential known as the Great Nest of Being and Knowing; as well as some deep structures or tenets of

11 evolution. 87,88,109 These limited pregivens can be integrated with the original principles of chiropractic's philosophy, such as the concepts of an Innate and Universal Intelligence, without giving them pregiven ontological status. The inherent drive toward organization posited of individual bodies (UR) and the universe (LR) can be understood as an aspect of the few pregivens Wilber claims. One important application of this approach is how it reframes the discussion of traditional chiropractic principles. For example, rather than dismissing innate intelligence as a heuristic metaphor reminding doctors to be more compassionate or conservative, 10,13 keeping it intact as strictly a biological principle, 6,16 attributing to it a sort of primal intuitive capacity, 27,110 or dismissing it outright as prescientific or prerational, 49,111 the concept can be discussed in terms of a deep structure of biological systems as a reflection of an even deeper structure of reality. Critiques can still be strongly presented; but a new wrinkle is allowed into the discussion, one that broadens and deepens the philosophical discourse in a rigorous way. Integral math Applying IMP to constructing a philosophy of chiropractic requires philosophers of chiropractic to systematically apply each of the 8 methodologies. Each methodology represents a perspective such as the inside view of the interior of the individual (introspection) or the outside view of the interior of

"I"

Fig 4.

"it"

inside

inside

outside

outside

subjective

objective

intersubjective

interobjective

"we"

"its"

inside

inside

outside

outside

“8 Primordial Perspectives,” from Wilber.87(p50)

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S. A. Senzon

the individual (structuralism). Wilber 87 developed Integral Math as a way to account for each of the 8 perspectives. The math is based on perspectives. The 3 main variable notations are described by EsbjörnHargens 101 (Table 1), the editor of the Journal of Integral Theory and Practice: first-person (1-p) or third-person (3-p) × inside (1-p) or outside (3-p) × interior (1p or 1p⁎pl) or exterior (3p or 3p⁎pl). When referring to 2nd person realities the “1p⁎pl” variable is used as the third variable since 2nd person is more technically understood as 1st person plural. Likewise “3p⁎pl” refers to interobjective realities. These three variables also represent quadrant × quadrivium × domain (where domain can either be a quadrant or a quadrivium).101(p86)

To clarify this notation system, 2 examples will be useful: UL quadrant and LL quadrant. The following examples can then be applied by the reader to the UR quadrant and the LR quadrant (Fig 5). The UL is the domain of “I” or the interior of the individual, the first-person perspective. This firstperson perspective can be viewed from the inside (introspection/phenomenology) or the outside (structuralism). First-person perspectives are written as 1-p; so any time we are referring to a subjective stance, we use 1-p. The view from the inside is also written as 1-p because it refers to a first-person perspective as well. Thus, if I were looking at my own interior thoughts or feelings, it would be notated as 1-p × 1-p. We would then add to this the domain or quadrant we are talking about. In this example of myself looking into my own feelings, because I am an individual, we would write 1p for UL quadrant. Thus, we would have the notation 1-p × 1-p × 1p or first-person perspective (1-p) from the inside (1-p) in the UL quadrant (1p). If however we are referring to using an objective external measure of my interior such as a quality of life survey instrument, a phenomenological survey instrument, or a developmental psychology survey instrument, that would be looking at my interior (1-p) from Table 1

Integral Math notation definitions

Notation

Definition

1-p 1p 3-p 3p 1p⁎pl 3p⁎pl

1st-person perspective Interior singular domain 3rd-person perspective Exterior singular domain Interior plural domain Exterior plural domain

1-p x 1-p x 1p

1-p x 3-p x 1p

3-p x 1-p x 3p

3-p x 3-p x 3p

subjective intersubjective

objective interobjective

1-p x 1-p x 1p*pl

3-p x 1-p x 3p*pl

1-p x 3-p x 1p*pl

Fig 5.

3-p x 3-p x 3p*pl

Integral Math notations, from Wilber.87(p52)

an objective perspective (3-p). Thus, we are no longer talking about me looking into my own feelings and thoughts, but examining my feelings and thoughts using objective criteria as might be applied by Piaget to study cognitive development 112-114 or Kohlberg to study moral development. 115 In that instance, the notation would be 1-p × 3-p × 1p, or first-person perspective (1-p) × looking from the outside or thirdperson perspective (3-p) in the UL quadrant (1p), because we are still talking about the individual's interior or the UL quadrant, “I.” For another example, let us talk about the interior of the collective in the LL, the domain of culture, shared meaning, and mutual understanding. In that case, we would still be talking about interiors because we are still in the left-hand quadrants; but now, we are talking about collectives. Therefore, if we are describing the interiors, we will stay with the notation of first person because it implies the subjective stance or the view from within (1-p). (If we were in the right-hand quadrants, this first notation would be 3-p, for third-person perspective.) The second part of the notation would remain the same as well, inside (1-p) or outside (3-p) views. (This would also be the case for the right-hand quadrants.) For the third part of the notation, however, we turn the subject into a plural of subjects; we add the term “⁎pl” to denote the domain of LL quadrant (1p⁎pl). The addition of “⁎pl” denotes the first-person plural or “We.” (In the case of the right-hand quadrants, for LR quadrant, the notation is 3p⁎pl; for UR quadrant, the

Constructing a philosophy of chiropractic notation is 3p.) This first-person plural would refer to the subjective stance of the culture: What is the overarching worldview of a culture? How do 2 or more individuals feel on the inside when together or resonating with each other? What are the chiropractic culture's shared meanings? All of these elements of meaning, mutual understanding, and shared resonance are depicted in this domain. When we are talking about collective interiors, or the LL, the notation for the inside view is 1-p (first person) × 1-p (inside) × 1p⁎pl (firstperson plural aka second-person perspective or “We”); and the notation for the outside view is 1-p (first person) × 3-p (outside) × 1p⁎pl. In the first case, the inside, we are referring to hermeneutics or the study of meanings; in the second case, the outside, we are discussing cultural anthropology or ethnomethodology, or structuralism applied to cultures. Esbjörn-Hargens 101 explains the 8 methodological families along with Integral Math as follows: The eight methodological families Wilber (2003) identifies are Phenomenology (1-p × 1-p × 1p), which explores direct experience (the insides of individual interiors); Structuralism (1-p × 3-p × 1p), which explores reoccurring patterns of direct experience (the outsides of individual interiors); Autopoiesis Theory (3-p × 1-p × 3p), which explores self-regulating behavior (the insides of individual exteriors); Empiricism (3-p × 3-p × 3p), which explores observable behaviors (the outsides of individual exteriors); Social Autopoiesis Theory (3-p × 1-p × 3p⁎pl), which explores selfregulating dynamics in systems (the insides of collective exteriors); System Theory (3-p × 3-p × 3p⁎pl), which explores the functional-fit of parts within an observable whole (the outsides of collective exteriors); Hermeneutics (1-p × 1-p × 1p⁎pl), which explores intersubjective understanding (the insides of collective interiors); and Cultural Anthropology (1-p × 3-p × 1p⁎pl), which explores recurring patterns of mutual understanding (the outsides of collective interiors).101(p88)

The philosophy of chiropractic has been discussed in terms of most of these perspectives but never in relation to all of the methods simultaneously. This is very important because it is common for authors, philosophers, researchers, and humans in general to be blinded to their own perspective and to engage the world including their own critique or support of a philosophical concept from one dominant perspective. 87,116 Divine 116 has even found that most people view the world through the lens of one of the quadrants. For

13 example, when a person “comes from” the UL quadrant, he or she wants to know how the situation relates personally to him or her; when a person “comes from” the UR quadrant, he or she wants to know what actions he or she could take or just the facts. When a person “comes from” the LL quadrant, he or she seeks to know how the situation might bring individuals together; and a person “coming from” the LR quadrant wants to know how the situation fits into a bigger system or context. It is easy to skip quadrants that you do not normally focus on and thus miss important elements of reality. By addressing each perspective and methodology systematically using Integral Math as a way to keep track of each methodological family, a comprehensive approach to philosophy of chiropractic can be entertained that forces each researcher or philosopher to include methods or perspectives that he or she may have missed. The “Discussion” section explores these 8 methods in more detail, while noting where they may be found or not found in the chiropractic literature. Integral Math and the 4 quadrants in general can be used to synthesize the work already done, scan for any missing elements or perspectives, 101,117 and then begin to construct a philosophy.

Discussion The 8 methodologies are described below in relation to the construction of a philosophy of chiropractic. It is important to note that each methodology such as phenomenology or systems theory represents a methodological family. That is, they are not the only methods able to disclose phenomena at each perspective. For example, the perspective of a first-person view of internal experience can be brought forth by contemplation, introspection, meditation, and phenomenology. Integral Methodological Pluralism summarizes all of these approaches or injunctions as phenomenology. 87 (p51) Each methodology described below represents a family of injunctions, which can also disclose phenomena apprehended at each particular perspective. Integral Methodological Pluralism is the map. The territory is composed of the principles of chiropractic; critiques of the philosophy; and other elements that philosophy could embrace such as ethics, morals, clinical choices, doctor-patient interaction, research methods, law, politics, and intra- and interprofessional social systems. Once the map is defined, future authors can freely fill in specific details and add any missing pieces. This article is meant to lay the first stage of the

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groundwork; it is not comprehensive. By simply ensuring that each perspective is mapped, many of the disagreements and debates from the past can be transcended. By allowing for each coexisting truth to be valid, if partial, a great step is made toward unifying the profession. The remaining dilemmas relate to a hierarchy or valuation of the partial truths, 26,82,109 which will be addressed in the second and third articles in the series. Phenomenology (1-p × 1-p × 1p) is a way to observe one's own consciousness systematically. It was first developed by Husserl and has significantly influenced Western philosophy in the last century. 118 In terms of the chiropractic encounter in respect to this methodology, when an individual receives a chiropractic adjustment, the internal feelings associated with health, illness, emotional, psychological, or spiritual wellbeing are validated so long as the individual is truthful. This first-person perspective represents the internal feelings, experiences, beliefs, and states of consciousness associated with the chiropractic encounter. Phenomenology has been suggested by several authors as a valuable contribution to the philosophy and research in chiropractic, and as a valuable qualitative method to research therapeutic effect, 119 to break away from the strict scientific rationality, 22,75 to understand patients in terms of their personal experience, 75 and to understand doctor-patient interactions, practice-based research, underlying factors of behavior, 7,8 and the emotional and psychological factors of health. 22 Kleynhans 5(p165) writes: The phenomenological approach to chiropractic would have as its purpose to seek a fuller understanding through description, reflection and other phenomenological methods the essence of lived experience of doctor and of patient related to experienced human relations and therapeutic interaction, space, time, body, etc. as lived by them—to reveal the multiplicity of coherent and integral meanings of this phenomenon.5(p165)

Coulter 10(p44) has noted how phenomenology is central to the “alternative paradigms” such as hermeneutics and ethnomethodology. As a reaction to the mind/body split inherent in the Western worldview and paramount in biomedicine, phenomenology helps the practitioner to focus on the dignity of the patient's lived experience. 10 According to O'Malley, 22 phenomenology can be used to distinguish between the art and science of chiropractic. The art is mediated through touch, and touch is based on phenomenological information.

O'Malley writes, “Because it is developed through experience, chiropractic art is not open to direct evaluation by the external observer whose experience is different from the chiropractor's.”22 (p288) Through touch, the chiropractor gains vital information about the patient's physical and emotional state and can even instill trust. Applying phenomenology to the philosophy of chiropractic should also extend to the philosophers and practitioners. This self-reflection may also relate to the higher ends of human function, especially regarding extraordinary claims of spiritual experiences, feeling “one with,” “innate,” “universal,” etc. Such systematic introspection has a long history in meditation practices and spiritual traditions such as Zen, Vipassana, and contemplative introspection. It can thus be used as a way to understand aspects of the philosophy of chiropractic that have traditionally been dismissed as mysticism, irrationality, and intuition. In the philosophy of chiropractic, phenomenology or systematic introspection has a tradition going back to DD Palmer and the books he was reading on the cultivation of the inner depths through meditation. 15,24,26,53 An overarching philosophy of chiropractic would acknowledge this domain, not only in terms of patient reports and practitioner-patient interaction, but also in regard to the original insights of the Palmers in terms of their own experiential explorations of consciousness. 15,27,44,46,78 Structuralism (1-p × 3-p × 1 p) is the systematic and objective tracing of invariant patterns over time. In terms of first-person perspectives, it applies to an individual's development through life. Every individual engages the world from a structure of consciousness without necessarily knowing his or her own structure. 87 Wilber points out that an individual can easily experience his or her first-person perspective (phenomenology), but cannot “see” his or her structure of consciousness without an objective measure to do so. Structuralism is another element left out of any philosophy of chiropractic. Structuralism has no correlates in the literature on chiropractic except for a few recent attempts. 15,27,44,47,78 Beyond that, the closest thing to this perspective within chiropractic is the objective measures of the patient's internal perceptions of health, wellness, or quality of life such as the Rand-36, the Global Well Being Scale, or the Health Related Quality of Life. 120-122 Although those qualitative measures apply an objective view to the individual's interior, they do not necessarily trace a structure of that interior through development. Structuralism, in this sense, refers to the development of an individual's complexity through life as

Constructing a philosophy of chiropractic pioneered by Piaget 112 and other developmental psychologists (although Piaget referred to himself as a genetic epistemologist). For example, an individual grows from prerational thinking as a child to rational thinking as an adult. This is a recurring change that can be objectively verified. 95,100 , 112-114 Constructivist developmental researchers have found at least 12 lines of development (moral development, cognitive development, aesthetic development, spiritual development, etc) whereby individuals may move through 5 to 12 levels in their life (prerational to rational to postrational) in each line. 95,100 (Recall that levels and lines are 2 of the 5 elements of IT.) Objectively examining individual interiors is an invaluable addition to constructing a philosophy of chiropractic. It allows for depth and objectivity in terms of understanding the perspectives individuals bring to the philosophy of chiropractic. It might also be applied to patient growth and development over time as well as practitioner-patient communications. There are at least 5 different cognitive structures of consciousness or perspectives in current use to discuss philosophy in chiropractic. 26 By acknowledging this, the many perspectives within chiropractic can be integrated. A recent integral biography of BJ Palmer examined his philosophical writings in terms of his development through life along several levels and lines.27 Developmental structuralism is one of the greatest contributions IMP can add to the construction of a philosophy of chiropractic. It is certainly one of the most neglected areas in the literature. It is the topic of the third article in this series. Autopoiesis Theory (3-p × 1-p × 3p) was developed by Maturana and Varela 123,124 to define the most essential characteristics of life; living systems are self-creating and knowing. The simplest example is how a cell creates its own parts and “knows” how to distinguish food from nonfood. This theory expands on concepts of homeostasis, dissipative structures, and chaos and complexity theory as it applies to a living organism. This is a very important point in regard to a philosophy of chiropractic because innate intelligence has been referred to as “a metaphor for homeostasis.” 13 (p85) As Wijewickrama 125 has pointed out, homeostasis as a reductionist concept does not capture the essential elements of life and health. He notes 3 components of a living system—self-will, autopoiesis, and selforganization—and several components of dynamic health, “which depicts increasing levels of organization and complexity in the interconnectedness of living system and environment.” 125(p10) Newell 81 has

15 described autopoiesis in terms of innate intelligence and the complex dynamic stability of the spine. Autopoiesis captures other elements of the definition of innate intelligence as well, especially in terms of the organism's ability to self-heal and “to know.” 46 Maturana and Varela 123 referred to the theory as Autopoiesis and Cognition. Chiropractic research in this domain would focus on the body's ability to selforganize. This view of the interior dynamics of the organism as self-organizing, self-regulating, and intelligent is the core of the philosophy of chiropractic in regard to the living organism. Most chiropractors view this aspect of the philosophy as central; therefore, it is an essential element of any wider philosophical system. Empiricism (3-p × 3-p × 3p), likely the second most widely embraced perspective in regard to the philosophy of chiropractic, is defined as the acquisition of knowledge through objective evidence. Several authors have suggested how empiricism is not an appropriate methodology as the sole arbiter of the chiropractic encounter. They cite empiricism's inherent limitations of worldview and method. Qualitative approaches 32,46,67,71 and alternative research paradigms such as phenomenology, 7,8,10 hermeneutics, and ethnomethodology 10,22 would be more appropriate to capture chiropractic's unique encounter. Dismissivists argue that empiricism should be the most weighted component of any philosophy, thus guiding clinical choices, research, and theory.3 From this perspective, objectivity is the only method to truth; and the objectivist perspective becomes the raison d'être of the profession, led by evidence-based research agendas. Villanova-Russell 67 relates this perspective to the encroaching hegemony of evidence-based medicine. She writes: The empiricism of EBM has become the gatekeeper to legitimacy and acceptance in mainstream health care today.… It is becoming clear that in order for alternative medical practitioners to survive, let alone be taken seriously by other health care professions, that they must conform to the standards of medicine even though their underlying philosophies, ontologies, epistemologies and methodologies are incongruent and not amenable to this evaluation.67(p556)

Jones-Harris 126 puts it more simply: “embrace empiricism or risk extinction.” 126(p74) Jamison 33 suggests that practitioners adopt “passive” and “active empiricism” 33 (p73) as a way to contribute to the philosophy. Passive empiricism is making the best clinical choices based on the available evidence. Active empiricism is to apply study designs to clinical research

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and produce case reports. Jamison emphasizes the need for the philosophy of science of chiropractic to pave the way for the future of the profession. Social Autopoiesis Theory (3-p × 1-p × 3p⁎pl) refers to the self-organizing nature of social systems. 109,127 Autopoiesis was extended to social systems by Luhmann. 127 His reasoning was that, much like living systems, social systems are operationally closed. For living systems, the closure defines the unity, boundaries, and autonomy. For social systems, the operational closure is in terms of communication. Luhmann writes: At first sight it seems safe to say that psychic systems, and even social systems, are also living systems. Would there be consciousness or social life without (biological) life? And then, if life is defined as autopoiesis, how could one refuse to describe psychic systems and social systems as autopoietic systems? In this way we can retain the close relation between autopoiesis and life and apply this concept to psychic systems and to social systems as well. We are almost forced to do it by our conceptual approach.127(p172)

The social system creates its own parts and communications, and maintains itself. Furthermore, it is populated by living beings (autopoietic organisms). This domain addresses the social, political, and economic pressures inherent to any profession, learning institution, professional organization, or accrediting agency. Historically, a philosophy of chiropractic has been shaped by all these forces. 25,28-30,45,56,65 Any element relating to communication and understanding between 2 or more individuals can be applied to this domain, such as doctor-patient interaction as described by Gatterman's 75 patient-centered paradigm, as well as the sociological and internal dynamics discussed by Coulter 10,128 in terms of clinic, health center, or profession. Following Luhmann's 127 logic, the philosophy of chiropractic can extend the philosophy of organism to its social institutions. The profession, governing bodies, individual clinics, and educational institutions would be viewed as self-maintaining, selforganizing, and self-producing systems. This perspective extends the holism of the philosophy into the social sphere. Systems Theory (3-p × 3-p × 3p⁎pl) was first described by Bertanalanffy 129 as a transdisciplinary approach fitting multiple parts together in a system by examining the general principles involved. Chiropractic literature addresses systems in several ways: to expand research methodologies; to include wider perspectives on philosophy in terms of the spinal

system 81 ; to contextualize the historical emergence of chiropractic's biological theories 130 ; and to describe the relationships between emergent health of body, mind, spirit, and environment. 46,131 Systems can also be applied to other objective analyses of social systems such as historical analysis. 28,43,45,56,132 Increasing understanding of how the philosophy of chiropractic is situated in historical, social, political, and economic systems is another useful application of systems theory. Hermeneutics (1-p × 1-p × 1p⁎pl) is the study of meaning between individuals and in culture. It has been applied to the philosophy of chiropractic in several instances, interpreting objective findings and finding meaning in illness through history-taking, 5 as a method to conduct practice-based research and understand behavior, 8 and as a method to interpret shared meaning through touch, thereby retaining the essence of chiropractic as a healing art. 22 O'Malley 22 writes, “Through phenomenology, it is possible to define the nature of experiential knowledge, and through the tools of hermeneutics it is possible to reveal the content of this knowledge to an external observer.” 22 (p287) O'Malley views the original philosophy of Palmer to be emancipatory for patients in healing of body, mind, and spirit; for practitioners in an embrace of both science and vitalism; and for the profession in the potential to help the world. He writes: A reconstructed philosophy of chiropractic must provide a complete framework for critical action. Rather than accepting that scientific rationality is the only valid truth for politicolegal legitimation, we must argue for the legitimacy of our own emic understanding of the healing process. This can be done within an inclusive framework using the tools of hermeneutics, phenomenology and critical theory.22(p291)

By examining mutual understandings between different schools of thought within chiropractic, definitions of professional jargon can be situated in a new way. Thus, understanding across the various schools can begin anew. This can also play an important role in the study of the patient-centered paradigm, as it emphasizes the importance of mutual resonance between the doctor and patient both verbally and through touch. 8,22,75 Cultural Anthropology (1-p × 3-p × 1p⁎pl) looks to the underlying and repeating structures in cultural worldviews. This perspective has been used in relation to the philosophy of chiropractic in terms of applying phenomenological methods to historical research. 133 Twenty years ago, Kleynhans 133 called for

Constructing a philosophy of chiropractic a “Historical Chiropractic,” where principles and practice can be studied in a historical context. 133(p140) One recent approach to bring an objective view to the culture of chiropractic was called for by Moore, 132 former editor of Chiropractic History. Moore writes: What I am calling for is a Social History of Chiropractic that moves outside the circle of internal chiropractic developments and its intramural aspects to a more broadly-gauged history that explores interaction with larger social and cultural developments.132(p60)

Moore 132 suggests that this type of Social history can be accomplished by examining broad questions that would bring the historian “deep into the heart of the American experience,” 132 (p61) to narrow questions such as: how chiropractic has been portrayed historically in comics, the arts, the role of women in chiropractic vs medicine, chiropractic's relationship to religion, sports, the media, etc. Other histories of chiropractic have focused on the impacts of belief systems and worldviews in wider cultural contexts.24,29,30,42 Tracing the structures of worldviews and how they change over time, a genealogy of worldviews, however, is mostly lacking in this regard. 15 Studying invariant structures of consciousness or worldviews is akin to structuralism (1-p × 3-p × 1p), but here it applies to the objective view of interiors of collectives. This approach was originally developed by Levi-Strauss 134 and in a cultural historical application by Gebser, 135 Habermas, 136 and Wilber. 109,137 Worldviews are pervasive in every culture and could be understood to underlie or be synonymous with paradigms. Although there has been a great deal written about paradigms and chiropractic philosophy,1,10,12,18,34,72,75,79,83,119,138,139 rarely has it taken a genealogical or developmental approach. 15 Without examining this deeper methodology in the construction of a philosophy of chiropractic, another important blind spot is traditionally missed. The second article in this series is devoted to this perspective, creating a cultural context for chiropractic's emergence, survival, and current trends.

Conclusions By offering an Integral framework through which a philosophy of chiropractic can be constructed, possibilities emerge toward integrating disparate worldviews, overcoming inherent contradictions, and furthering

17 professional unity. Including these 8 irreducible perspectives within the philosophy of chiropractic reflects a postmetaphysical stance drawing from ideas and criticisms in premodern, modern, and postmodern approaches to knowledge. Basic debates plaguing the profession for decades can now be integrated. For example, the decision to focus on Empiricism (3-p × 3-p × 3p) or Autopoiesis (3-p × 1-p × 3p) becomes a moot point, as it becomes obvious that each represents 2 parts of any perspective on the body. When questioning whether chiropractic's philosophy includes Spirit in its definitions of life, health, and well-being, acknowledgment of its importance for individuals (UL) in the context of specific cultural (LL) and social (LR) circumstances becomes relevant, yielding an understanding of associated neurophysiological correlates (UR) such as the “godspot” in the brain,87 as well as consciousness studies (UL), which was recently described as an important element in exploring the philosophy of chiropractic. 83 Furthermore, when an individual uses Phenomenology (1-p × 1-p × 1p), he or she describes internal experiences of Spirit based on his or her particular worldview (Structuralism/Cultural Anthropology). Rather than positing Spirit as a metaphysical given, the philosophy of chiropractic can acknowledge the importance of post-Kantian and post-Heideggerian thinking (modern and postmodern), while accepting the validity claim of the individual's experience. 88 Even more specifically, IT and IMP can be used to deconstruct any approach to the philosophy of chiropractic. For example, the system proposed by Coulter, 10 developed at Los Angeles College of Chiropractic in the 1990s 80 and now widely embraced in the profession, 1,2,18,60,74,83,84 posits 6 philosophies that comprise the philosophy of chiropractic: vitalism, holism, naturalism, therapeutic conservatism, humanism, and critical rationalism. A cursory examination determines whether this system meets the criteria of being fully inclusive and postmetaphysical simply by applying the framework. Immediately, the lack of at least 2 perspectives, Structuralism (1-p × 3-p × 1 p) and Cultural Anthropology (1-p × 3-p × 1p⁎pl), becomes apparent in regard to developmental and genealogical approaches to those methodologies. 95 ,112-114 ,133 Including those would make the system more holistic. A discussion of the pregivens associated with such a system is another way IMP could be useful. Another partial approach to the chiropractic paradigm was described by Cleveland et al. 12 This too will be described in future articles; but as an example, they suggest that a philosophy of chiropractic should

18 dismiss all metaphysical baggage and emphasize the self-healing aspect of living organisms. Like Coulter's 10 approach above, this approach is lacking the methodologies Structuralism (1-p × 3-p × 1 p) and Cultural Anthropology (1-p × 3-p × 1p⁎pl), more than anything else. Without explicitly addressing the perspectives of the authors, the perspectives of the theories or paradigms, and the worldviews being considered both historically and in a contemporary way, any approach will be incomplete. These approaches will be addressed in 2 more articles. The first will address cultural worldviews, and the second will address personal structures of consciousness. As noted above, these are 2 of the greatest blind spots in discussing philosophy of chiropractic. By clarifying these 2 aspects of the map, all other territories can be built upon more easily. Any attempt to create a discipline of philosophy in chiropractic without coming to terms with IT and IMP will always remain partial, leave something out, and be unable to bring all aspects of the profession on board to engage in the discussion. Great effort is required for philosophers in the profession to flesh out this deep and expansive approach. If it is done well, philosophy can become a meaningful guide to the chiropractic profession.

Acknowledgment The author would like to thank Sherri McLendon, MA; Christopher Kent, DC, JD; and Donald Epstein, DC, for editorial suggestions.

Funding sources and potential conflicts of interest Simon Senzon has received from the Global Gateway Foundation a research and writing grant to further the objectives of the Foundation.

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19 50. Hanegraaff W. New age religion and Western culture: esotericism in the mirror of secular thought. Albany, NY: State University of New York Press; 1998. 51. Beck B. Magnetic healing, spiritualism, and chiropractic: Palmer's union of methodologies, 1886-1895. Chiropr Hist 1991;11(2):11-6. 52. Senzon SA. A history of the mental impulse: theoretical construct or scientific reality? Chiropr Hist 2001;21(2): 63-76. 53. Senzon SA. Chiropractic and energy medicine: a shared history. J Chiropr Humanit 2008;15:27-54. 54. Oschman J. Energy medicine: the scientific basis. New York: Churchill Livingstone; 2000. 55. Wisneski L, Anderson L. The scientific basis of integrative medicine. 2nd ed. Boca Raton, FL: CRC Press; 2009. 56. Peterson D, Weise G. Chiropractic: an illustrated history. St. Louis: Mosby; 1995. 57. Redwood D, Cleveland C. Fundamentals of chiropractic. St. Louis: Mosby; 2003. 58. Leach R. The chiropractic theories: a textbook of scientific research. 4th ed. Philadelphia: Lippincott; 2004. 59. Haldeman S, editor. Principles and practice of chiropractic. New York: McGraw-Hill; 2004. 60. Gatterman M. Foundations of chiropractic subluxation. 2nd ed. St. Louis: Mosby; 2005. 61. Donahue J. A proposal for the development of a contemporary philosophy of chiropractic. Am J Chiropr Med 1989;2(2): 51-3. 62. Strauss J. Refined by fire: the evolution of straight chiropractic. Levittown, PA: Foundation for the Advancement of Chiropractic Education; 1994. 63. Jacelone P. The ancient philosophic roots of chiropractic literature. Chiropr Hist 1989;9(2):45-9. 64. Phillips R. The battle for innate: a perspective on fundamentalism in chiropractic. J Chiropr Humanit 2004;11:2-8. 65. Martin S. Chiropractic and the social context of medical terminology 1895-1925. Technol Cult 1993;34(4):808-34. 66. Baer H. Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States. Med Anthropol Q 1987;1(2):176-93. 67. Villanueva-Russell Y. Evidence-based medicine and its implications for the profession of chiropractic. Soc Sci Med 2005;60:545-61. 68. General Chiropractic Council. Guidance on claims made for chiropractic vertebral subluxation complex. Available from: http://www.gccuk.org/files/link_file/Guidance_on_claims_ made_for_the_chiropractic_VSC_18August10.pdf. Accessed September 6, 2010. 69. Haavik-Taylor H, Holt K, Murphy B. Exploring the neuromodulatory effects of vertebral subluxation. Chiropr J Aust 2010;40:37-44. 70. GCC revises guidance on claims made for the vertebral subluxation complex. Chiropractic Economics Online. Available from: http://www.chiroeco.com/chiropractic/news/ 10150/52/gcc-revises-guidance-on-claims-made-for-the-vertebral-subluxation-complex-/. Accessed September 15, 2010. 71. Kent C. An analysis of the General Chiropractic Council's policy on claims made for the vertebral subluxation complex. Foundation for Vertebral Subluxation. Available from: http:// www.mccoypress.net/subluxation/docs/kent_gcc_subluxation_ analysis.pdf. Accessed September 5, 2010.

20 72. Kleynhans A, Cahill D. Paradigms for chiropractic research. Chiropr J Aust 1991;21:102-7. 73. Esbjörn-Hargens S. An overview of integral theory: an all-inclusive framework for the 21st century [resource paper no. 1]. Integral Institute 2009;1-24. Available from: http:// integrallife.com/files/Integral_Theory_3-2-2009.pdf. Accessed October 24, 2010. 74. Donahue J. Are philosophers just scientists without data? Phil Constructs Chiropr Prof 1991;1(1):21-4. 75. Gatterman M. A patient-centered paradigm: a model for chiropractic education and research. J Am Chiropr Med 1995; 1(4):371-86. 76. Keating J. Beyond the theosophy of chiropractic. J Manipulative Phys Ther 1989;12:147-50. 77. Koch D. Has vitalism been a help or a hindrance to the science and art of chiropractic? J Chiropr Humanit 1997;6:18-22. 78. Senzon S. An integral approach to unifying the philosophy of chiropractic: B.J. Palmer's model of consciousness. J Conscious Evol 2000;2:1-20. 79. Callendar A. The mechanistic/vitalistic dualism of chiropractic and general systems theory: Daniel D. Palmer and Ludwig von Bertalanffy. J Chiropr Humanit 2007;14:1-21. 80. Phillips R, Coulter I, Adams A, Traina A, Beckman J. A contemporary philosophy of chiropractic for the LACC. J Chiropr Humanit 1994;4:20-5. 81. Newell D. Concepts in the study of complexity and their possible relation to chiropractic health care: a scientific rationale for a holistic approach. Clin Chiropr 2003;6:15-33. 82. Astin J. Does the chiropractic profession need a common conceptual framework? Proceedings of the World Federation of Chiropractic Conference on Philosophy in Chiropractic Education; 2000 Nov 11-12; Fort Lauderdale, Fla; Toronto: WFC; 2000. 83. Chapman-Smith E. (ed.). Philosophy, practice and identity: why agreement is needed and what is being done. In: The chiropractic report 2003;17 (Vol. 3):1-8. 84. WHO guidelines on basic training and safety in chiropractic. Geneva: World Health Organization; 2005. p. 9. 85. Wilber K. Excerpt B: the many ways we touch: three principles helpful for any integrative approach. Available from: http:// www.kenwilber.com/writings/read_pdf/84. Accessed September 18, 2010. 86. Wilber K. The collected works of Ken Wilber. Boston: Shambhala; 1999-2000. 87. Wilber K. Integral spirituality. Boston: Shambhala; 2006. 88. Esbjörn-Hargens S, Wilber K. Toward a comprehensive integration of science and religion: a postmetaphysical approach. In: Clayton P, Simpson Z, editors. The Oxford handbook of religion and science. Oxford, UK: Oxford University Press; 2006. 89. Astin J, Astin A. An integral approach to medicine. Altern Ther Health Med 2002;8(2):70-5. 90. George L. Integral medicine: an AQAL based approach. J Integral Theory Pract 2006;1(2):38-59. 91. Fiandt K, Forman J, Megel E, Pakieser R, Burge S. Integral nursing: an emerging framework for engaging the evolution of the profession. Nurs Outlook 2003;51(3): 130-7. 92. Dossey B. Integral and holistic nursing. In: Dossey B, Keegan L, editors. Holistic nursing: a handbook for practice, 5th ed. Sudbury, MA: Jones & Bartlett; 2008. p. 3-46.

S. A. Senzon 93. Goddard T. Integral healthcare management: an introduction. J Integral Theory Pract 2004;1(1):449-58. 94. Wilber K. An integral theory of consciousness. J Consciousness Stud 1997;4(1):71-92. 95. Combs A. Consciousness explained better: towards an integral understanding of the multifaceted nature of consciousness. St. Paul, MN: Paragon House; 2009. 96. Koller K. An introduction to integral science. J Integral Theory Pract 2004;1(2):237-49. 97. Esbjörn-Hargens S, Zimmerman M. Integral ecology: uniting multiple perspectives on the natural world. New York: Random House/Integral Books; 2009. 98. Murray T. What is the integral in integral education? From progressive pedagogy to integral pedagogy. Integral Rev 2009;5(1):96-134. 99. Wilpert G. Integral politics: an integral third way. J Integral Theory Pract 2004;1(1):72-89. 100. Wilber K. Integral psychology: consciousness, spirit, psychology, therapy. Boston: Shambhala; 2000. 101. Esbjörn-Hargens S. Integral research: a multi-method approach to investigating phenomena. Constr Human Sci 2006;2 (1):79-107. 102. Wilber K, Patten T, Leonard A, Morelli M. Integral life practice: a 21st century blueprint for physical health, emotional balance, mental clarity, and spiritual awakening. New York: Random House/Integral Books; 2008. 103. Hunt J. Transcending and including our current way of being: an introduction to integral coaching. J Integral Theory Pract 2009;4(1):1-20. 104. JFKU.edu [Internet]. Pleasant Hill, CA: John F. Kennedy University; c2010 [cited 2010 Sep 18]. Available from: http:// www.jfku.edu/Programs-and-Courses/College-of-Professional-Studies/Integral-Studies.html. 105. SunyPress.edu [Internet]. Albany, NY: State University of New York Press; c2010 [cited 2010 Sep 18] Available from: http://www.sunypress.edu/p-5108-journal-of-integral-theoryand-practice.aspx. 106. Integral-Review.org [Internet]. Bethel, OH: ARINA, Inc.; c2010 [cited 2010 Sep 18] Available from: http://www. integral-review.org/. 107. IntegralTheoryConference.org [Internet]. Pleasant Hill, CA: John F. University;c2010 [cited 2010 Sep 18]. Available from: http://www.integraltheoryconference.org. 108. SunyPress.BlogSpot.com [Internet]. Albany, NY: State University of New York Press. c.2010 [cited 2010 Sep 18]. Available from: http://sunypress.blogspot.com/2010/03/ integral-theory.html. 109. Wilber K. Sex, ecology, spirituality: the spirit of evolution. Boston: Shambhala; 1995. 110. Palmer B. The bigness of the fellow within. Davenport, IA: Palmer School; 1949. 111. Weiant C. Chiropractic philosophy: the misnomer that plagues the profession. 112. Piaget J. The principles of genetic epistemology: collected works. London: Routledge; 1997. 113. Cook-Greuter S. Making the case for a developmental perspective. Ind Commercial Training 2004;36(7): 275-81. 114. Kegan R, Lahey L. The immunity to change: how to overcome it and unlock the potential in yourself and your organization. Cambridge, MA: Harvard University Press; 2009.

Constructing a philosophy of chiropractic 115. Kohlberg L. The philosophy of moral development: moral stages and the idea of justice. San Francisco: Harper and Row; 1981. 116. Divine L. Looking at and looking as the client: the quadrants as a type structure lens. J Integral Theory Pract 2009;4(1):21-40. 117. Cook-Greuter S. AQ as scanning and mapping device. J Integral Theory Pract 2006;1(3):142-57. 118. Husserl E. Phenomenology and the Crisis of Philosophy. New York: Harper & Row; 1965. 119. Miller P. Phenomenology: a resource pack for chiropractors. Clin Chiropr 2004;7:40-8. 120. Hawk C, Dusio M, Wallace H, Bernard T, Rexroth C. A study of reliability, validity, and responsiveness of a self-administered instrument to measure global well-being. Palmer J Res 1995;2(1):15-22. 121. Hoiriis K, Owens E, Pfleger B. Changes in general health status during upper cervical chiropractic care: a practice-based research project. Chiropr Res J 1997;4(1):18-26. 122. Blanks R, Schuster T, Dobson M. A retrospective assessment of network care using a survey of self rated health, wellness, and quality of life. J Vertebr Subluxat Res 1997;1(4):11-27. 123. Maturana H, Varela F. Autopoiesis and cognition: the realization of the living. Dordrecth: D. Reidel Pub. CO; 1980. 124. Maturana H, Varela F. The tree of knowledge. Boston: Shambhala; 1987. 125. Wijewickrama D. Chiropractic and cybernetics. J Chiropr Humanit 2001;10:1-13. 126. Jones-Harris A. The evidence-based case report: a resource pack for chiropractors. Clin Chiropr 2003;6:73-84.

21 127. Luhmann N. The autopoiesis of social systems. In: Geyer F, van der Zouwen J, editors. Sociocybernetic paradoxes. London, UK: Sage Publications; 1986. p. 172-92. 128. Coulter I. Sociological studies of the role of the chiropractor: an exercise in ideological hegemony? J Manipulative Phys Ther 1991;14(1):51-8. 129. Bertalanaffy L. General system theory: foundations, development, applications. New York: George Braziller; 1968. 130. Senzon S. What is life? J Vertebr Subluxat Res 2003:1-4. 131. Beckman J, Fernandez C, Coulter IA. Systems model of health care: a proposal. J Manipulative Phys Ther 1996;19(3): 208-15. 132. Moore J. Reflections on healing, orthodoxy, and a new direction for chiropractic history. Chiropr Hist 2009;29(1):55-65. 133. Kleynhans A. Historical chiropractic: part 1: delineation. Chiropr J Aust 1990;20:139-42. 134. Levi-Strauss C. The elementary structures of kinship. New York: Beacon Press; 1971/1949. 135. Gebser J. The ever-present origin. Athens, OH: Ohio University Press; 1949. 136. Habermas J. The theory of communicative action: life world and system: a critique of functional communicative action (vol 2). Boston: Beacon Press; 1985. 137. Wilber K. Up from Eden: a transpersonal view of human evolution. Wheaton, OH: Quest Books; 2007/1981. 138. Kleynhans AA. Chiropractic conceptual framework: part 4: paradigms. J Chiropr Austr 1999;29:129-36. 139. Leach R, Phillips R. Philosophy: foundation for theory development. In: Leach R, editor. The chiropractic theories: a textbook of scientific research, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2004.

Journal of Chiropractic Humanities (2010) 17, 22–32

Commentary

Historical overview and update on subluxation theories☆ Howard Vernon DC, PhD⁎ Professor, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada M2H 3J1 Received 4 June 2010; received in revised form 22 July 2010; accepted 22 July 2010 Key indexing terms: Chiropractic; Philosophy; Review

Abstract Objective: This article presents a personal view of the historical evolution of theories of subluxation in the chiropractic profession. Discussion: Two major themes emerge from this review: those related to the mechanical behavior of the spine and those related to the neurologic implications of these mechanical issues. Chiropractic subluxation theory is one of the few health-related theories whereby these mechanical and neurologic theories have been unified into a comprehensive theory of disorder of spinal function. For this disorder, doctors of chiropractic have used the term subluxation. These theories, and their unification in the “subluxation concept,” have undergone evolution in the profession's history. Conclusion: The “subluxation concept” currently faces challenges, which are briefly reviewed in this article. The only way forward is to strengthen our efforts to investigate the “subluxation concept” with high-quality scientific studies including animal models and human clinical studies. © 2010 National University of Health Sciences.

Introduction Manual therapy has, arguably, best been described by a Polish medical manipulation practitioner, Arkuszewski, 1 as “a mechanical therapy with reflex effects.” The phrase mechanical therapy can be further characterized by noting that it is performed in the musculo-

☆

Previous presentation: Portions of this article were presented at Colloquium on “Reconciling Subluxation and Science,” Canadian Memorial Chiropractic College, October 25, 2009. ⁎ Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, Ontario, Canada M2H 3J1. Tel.: +1 416 482 2340; fax: +1 416 482 2560. E-mail address: [email protected].

skeletal (MSK) system. The phrase reflex effects can be further qualified, at the very least, to indicate that these are “health-beneficial.” Therefore, a revised version would read as follows: “a manually-performed mechanical therapy to the MSK system with health-beneficial reflex effects.”

This formulation also provides a basis for describing the primary disorder posited by chiropractic theory: subluxation. Recognizing that, for chiropractic, the subluxation has always been viewed as the “thing for which adjustment (manual therapy) is done,” a firstpass definition of subluxation, a la Arkuszewski, would be “a mechanical problem in the musculoskeletal system with health-deleterious reflex effects.”

1556-3499/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.echu.2010.07.001

Subluxation theories Since the founding of chiropractic and the other manual therapy professions, 2 fundamental issues have vexed us: 1. What kind and location of mechanical problem in the MSK system qualifies as a subluxation (or any of the other terms used as synonyms within and outside of chiropractic)? 2. What kind of health-deleterious effects are specifically associated with subluxation? The author recognizes that numerous others have attempted to review the subluxation concept, including recent excellent reviews by Gatterman, 2 Peters, 3 and Ebrall. 4 These previously published discussions are not reviewed here. What follows is a nonsystematic overview of selected developments in the profession that have addressed these 2 questions.

Discussion The archetypical and founding event in the history of the chiropractic profession is Daniel David Palmer's first treatment of Harvey Lillard. From Palmer's original work, 5 he describes his thinking leading up to this event as: “Displacement of any part of the skeletal frame may press against nerves, which are the channels of communication, intensifying or decreasing their carrying capacity, creating either too much or not enough functionating [sic], as aberration known as disease.” “Pressure on nerves causes irritation and tension with deranged functions as a result. Why not release the pressure? Why not a just cause instead of treating the effects? Why not?” “I claimed to be the first person to adjust a vertebra by hand, using the spinous and transverse processes as levers. I developed the art known as adjusting.…” “The basic principle, and the principles of chiropractic which have been developed from it, are not new. They are as old as the vertebrae.… I am not the first person to replace a subluxated vertebra, for this art has been practiced for thousands of years.”

Palmer relates that he came upon this theory and applied it first to a man with deafness. Keating 6 records this version of events:

23 “Harvey Lillard gave him the cue which opened a new field for research. Mr. Lillard was restored to hearing by two adjustments, a dorsal vertebrae was replaced in its normal position.”

Here is Harvey Lillard's rendition of these events according to Palmer's newsletter: “I was deaf for 17 years and I expected to always remain so, for I had doctored a great deal without any benefit. I had long ago made up my mind to not take any more ear treatments, for it did me no good. Last January Dr. Palmer told me that my deafness came from an injury in my spine. This was new to me; but it is a fact that my back was injured at the time I went deaf. Dr. Palmer treated me on the spine; in two treatments I could hear quite well. That was 8 months ago. My hearing remains good.” Harvey Lillard, 320 W Eleventh St, Davenport, Iowa.6

Although Palmer articulated several versions of his theory, the archetypal elements of Palmer's theory follow a logical pattern, as follows: 1. Subluxation, which is a misalignment of one of the vertebrae, causes 2. pressure on nerves exiting around the vertebrae, causing 3. disease. Therefore, 4. Removal of subluxation (by manually adjusting it to its correct position) causes 5. release of nerve pressure, causing 6. the restoration of health. Fig 1 is a schematic depiction presenting this foundational chiropractic model. It also depicts the author's view of the evolution of this model through the 20th century. An important early advancement was the transformation of the understanding of the activity of the nervous system from a vitalistic interpretation, as the “flow of Innate Intelligence,” to a mechanistic or physiologically-based understanding of function in the nervous system. It appears that this understanding was not fully mature, as it focused only on the efferent neural activity that could be compromised by nerve compression, that is, neural conduction and efferent innervation of end organs. This produced a formulation whereby nerve compression was understood to result in an interference or derangement of nerve function, as

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Fig 1.

Historical evolution of the “subluxation model.”

understood in purely physiologic terms, which then resulted in end-organ dysfunction or disease. One manifestation of this approach was the development of the Meric system by BJ Palmer and James C Wishart 7 that organized this “physiologic view” of neural regulation according to the spinal segmental level of the peripheral nerves and their end-organ territories of innervation. This development allowed many chiropractors to leave their vitalistic heritage behind to its rightful place in the history of ideas and move into a solidly, if not fully, mature physiologic/pathophysiologic model (Fig 1). Another important advancement came with a change in the conception of the type of mechanical derange-

ment that could constitute a subluxation. As noted above, for Palmer and the early chiropractors, this was ‘misalignment’ of the vertebra. By the 1920s, several chiropractic thinkers 8-11 had begun to shift their focus from static misalignment to some kind of “disturbance of function.” However, this required a fundamental change in thinking from a primary and very limited focus on “bone” (vertebra) to a more expanded focus on “joint” (spinal motion segment). This shift was critical in the evolution of a scientific model for chiropractors. It changed our practice, by emphasizing different technical procedures for the assessment of joint function, well beyond the limits of determining static misalignment of a bone. As well, it prepared the way

Subluxation theories for the other major changes described below by grounding the theory of subluxation at the level of the joint, not the level of a single bone, and the pressure it could exert on nerves. This led the way to the next important shifts that characterize the major theoretical advancement of the late 1940s to the 1960s: maturation of the understanding of effects on and contribution of the nervous system (ie, “reflexes”) related to the subluxation. This work is associated with Dr Irwin Korr et al 12-19 and was echoed in chiropractic by many, including, but not limited to, Dr AE Homewood 20 in the late 1950s as well as his students, Drs R Gitelman 21,22 and A Grice 23 from the Canadian Memorial Chiropractic College and Dr S Haldeman 24 from the Palmer College of Chiropractic. This next step in the evolution of chiropractic thinking involved a shift from a focus solely on nerve compression to include the emerging understanding of the neural or reflex mechanisms that result directly from injury to the deep tissues of the vertebral motion segment. This shift incorporated the understanding of the effects of pain and inflammation from, for example, the facet joints of the spinal segments, on spinal cord mechanisms of sensory-motor integration and autonomic outflow. For Korr, this was termed the facilitated segment and led to his theory of “central excitatory state (CES)”.14-20 The notion of “spinal irritability” had been developed as early as 100 years prior and had been part of the work of Head25 and others in the early 20th century. 26-29 The work of Korr, Denslow, Wright, 12-19 and others revived this idea; and it was then applied in osteopathic and chiropractic thinking. Since that time, this model has come to be known as central sensitization (see below); and it has received enormous attention from pain researchers around the world. A corollary to this development was the shift from a focus, especially in early chiropractic, which was solely on “efferent” or “downstream” neural mechanisms (those affected by compression), to a more comprehensive understanding of sensory-motor interactions within the central nervous system. In early chiropractic thinking, the “Big Idea” was to consider the action of “Innate Intelligence,” as it flowed through the nervous system, as working from “above-down, inside-out.” In this theory, blockage of a nerve by a misaligned vertebra resulted only in a blockage of the outward flow of health-giving “innate.” Once the shift of thinking beyond static misalignment of a vertebra to dynamic behavior of a spinal motion segment (joint) occurred, chiropractors could begin thinking about the sensory

25 implications of their “lesion.” Along with the shift away from spinal nerve compression mentioned above, this shift laid the groundwork for a much more sophisticated, fully scientifically grounded neural theory of “subluxation.” Korr summarized these developments in his famous categorization of “impulse-” and “non– impulse-based” mechanisms of the spinal lesion. It is actually better to consider these as “nerve compression–based” and “non–nerve compression– based” mechanisms. It will be instructive to fill in some of the voluminous work that has ensued on these themes since that time. This follows immediately after the next section. Fig 2 summarizes some of the notable historical developments in the neurosciences of manipulation. Contemporaneous with this work on the “neural side” of the subluxation story was the work on the mechanical side undertaken by such notables as Drs Fred Illi, 30 Joe Janse, 31 Henri Gillet and his colleague Liekens, 32,33 as well as their North American students, Drs L John Faye,34 Ron Gitelman, 22 and Adrian

Fig 2. Historical review of developments to subluxation theory.

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H. Vernon

Grice. 23 Notable developments in these mechanical approaches to the “subluxation” were: – the development of motion palpation (although there is a history of interest in this going back to the 1930s with the work of Grecco and others) – the development of concepts such as “joint play,” “end-feel,” etc (the work of Mennel 35 is also important in this regard) – the elucidation of complex segmental motions by end-motion radiographs leading to an understanding of reference ranges of segmental motion, “coupled motion,” and axes of motion – the use of spinal-pelvic cineradiography – the use of weight scales and posturometers to assess full body posture – interest in gait mechanisms – an expanded biomechanical model that grounded single spinal subluxations within the larger context of the vertebral column and the locomotor system and considered the assessment and treatment of ‘patterns of findings’ (vs single separate findings) in these larger contexts. I call this model structural wholism. Aside from this work representing a shift toward the dynamic, functional aspects of the spine, it also represented a shift away from single vertebral analysis (subluxation listings etc) to a more sophisticated analysis of, and interest in, the entire locomotor system. In fact, the definition of chiropractic developed at the Canadian Memorial Chiropractic College in the late 1960s was: “A discipline of the scientific healing arts concerned with the pathogenesis, diagnostics, therapeutics, pain syndromes and neurological effects related to the statics and dynamics of the locomotor system, especially of the spine and pelvis.”36

The emphasis on the phrase locomotor system is mine, showing how that term predominated in the thinking of that time. Notice that no mention of “subluxation” is found. In a countermovement to this development, a new model called the vertebral subluxation complex was promulgated by Faye and Lantz. 34,37 It is the author's opinion that this model may have created unwanted and unnecessary complexity in the numerous categories and aspects of tissue and physiologic functioning applied to the concept of subluxation, such as histopathology, myopathology, neuropathology, etc. All tissue sites or structures in the body—somatic,

neural, and visceral—have these many dimensions or aspects (ie, all of these “ologies”). In the author's opinion, this model did not contribute to the scientific advancement, especially the scientific elucidation, of the subluxation concept. In the author's opinion, another similar unfortunate development was the American Chiropractic Association paradigm statement on subluxation in 1996: “Chiropractic … focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” (from Gatterman38)

This “definition” is too ambiguous and tentative, with its many “and/ors” and conditional assertions; and it has yet to be shown how this definition has contributed to the scientific development of the “subluxation concept.” In more recent times, a consensus appears to have been reached in the manual therapy academic literature around the nature of the mechanical problem in the spine amenable to manual therapy, namely, hypomobility associated with a disturbance of joint function, hence, the terms joint dysfunction or, for the spine, spinal or segmental dysfunction. The International Association for the Study of Pain Classification of Chronic Pain includes a definition of segmental dysfunction (in each of the spinal regions), as follows: “(spinal) pain, ostensibly due to excessive strains sustained by the restraining elements of a single spinal motion segment. … features (spinal) pain, with or without referred pain, that can be aggravated by selectively stressing the particular spinal segment. Diagnostic criteria (all of the following should be satisfied): 1. The affected segment must be specified. 2. The patient's pain is aggravated by clinical tests that selectively stress the affected segment. 3. Stressing adjacent segments does not reproduce the patient's pain. Pathology: Unknown. Presumably involves excessive strain incurred during activities of daily living by structures such as the ligaments, joints or intervertebral disc of the affected segment.”39, p111

Subluxation theories Recent and current concepts The following recounts the development of ideas on the neurologic and mechanical issues relevant to subluxation from the 1960s onward and includes a short list of recent developments that are important to the development of the modern “subluxation model.” A. Neurologic mechanisms A.i Nerve compression–based mechanisms. 1. Chiropractors received considerable and protracted scorn for the idea of a “pinched nerve.” Crelin's 40 effort to debunk chiropractic focused directly on this phenomenon by putatively showing that there was ample room in the intervertebral foramen (IVF) for the nerve to never undergo such compression. The phenomenon of nerve compression became very strongly associated with disk herniation after Mixter and Barr's 1934 article. The role of minor intervertebral joint derangement in compression on nerves and in referred back pain became greatly diminished in the “medical model.” 2. However, the link between herniated disks and nerve compression did eventually loosen so that, by the 1970s, the phenomenon of lateral entrapment of the spinal nerve root had become well accepted. The work of Sharpless, 41 Sutherland,42,43 and Luttges and Gerren 44 on nerve root compression susceptibility and the work of Rydevik et al 45-53 “rehabilitated” the concept of the compressed nerve in spinal diagnosis. Several chiropractic researchers investigated the effects of nerve root compression in the IVF by using animal models (see reviews by Vernon54 and Henderson55 ). Disturbances of nerve conduction velocity and neural axoplasmic flow were demonstrated. However, these studies only provided an animal model of what might occur if “the subluxation really did result in compressed nerves.” Actual compression of nerves by something that most would agree was a subluxation was not studied. The mechanical derangement of the subluxation is not easy to create in an animal model. Most importantly, for our purposes of discussion in modern pain research circles, this type of research goes under the name of neuropathic pain. It is clear that compression/irritation of the peripheral nerves, either as nerve roots or as nerve trunks, results in profound changes in sensorimotor processing throughout the central nervous system, but especially in the spinal

27 cord. This means that, all along, compression of nerves was not just an “inside-out” matter. There is a whole dimension of “outside-in” (centripetal) processes that involve highly complex and clinically important changes in central sensorimotor processing that then results in profound changes in sensory, motor, and autonomic functions. In other words, we now know that nerve compression/neuropathic pain is a much more complex matter than was originally conceived by the early chiropractors; and if, as part of the modernization of our thinking on subluxation, we believe that a role for nerve compression should be preserved, we should do so only with great respect and full regard for the body of data now available on the matter. 3. Recent work has shown that facet inflammation can induce compressive radiculopathy by spread of inflammatory exudate anteriorly into the IVF. 56 Therefore, spinal joint dysfunction/inflammation can lead to direct nerve compression (ie, neuropathic pain) and not just “reflex” effects from pain (see below). Ironically, this work convincingly refutes Crelin's infamous report and finally provides confirmation of the oldest chiropractic theory: that relatively minor problems in the small joints of the spine can actually deleteriously compress or irritate the adjoining nerve! A.ii Nonnerve compression–based mechanisms. 4. Since the 1970s, a great deal has been learned about deep somatic pain mechanisms, that is, pain from deep somatic—muscle, joint, ligament— sources. This is an advance on the situation whereby the great preponderance of knowledge of pain mechanisms before that time came from studies of cutaneous sources only. Deep pain mechanisms have been strongly associated with the development of central sensitization in the central pain transmission system: dorsal root ganglion cells, spinal cord dorsal horn, projection tracts to the brain, wide-ranging brain-based mechanisms in the medulla, midbrain, thalamus, and sensory cortex. As well, deep pain mechanisms are now known to evoke antinociceptive mechanisms local to the spinal cord as well as descending to the cord from midbrain nuclei. 5. Central sensitization involves such changes dorsal horn neurons as lowered thresholds excitation, prolonged after-discharges, spread reactivity of dorsal horn neurons, increases the peripheral receptive fields, and a host

in of of in of

28

H. Vernon molecular and cellular/synaptic changes that underlie these functional changes. All of these changes are thought to be responsible for the clinical phenomena of spread of pain from an initial source, referral of pain from the original source, the development of allodynia and other hypersensitivity states, the development of chronicity of pain by virtue of the persistence of these changes (long-term potentiation), and the development of recurrence by virtue of the creation of persisting neural engrams or “pain memories.”

These changes are also now regarded as the mechanisms responsible for the efferent manifestations of the subluxation, as they were conceived in the theory of the “central excitatory state”: reflex muscular hypertonicity, reflex autonomic changes (somatovisceral mechanisms), and the functional changes that result from these manifestations, such as reduced mobility of the joints, contractures of muscles, altered patterns of joint use and function, altered tissue health, etc. The fact that so much more is now known about the mechanisms of central sensitization and the particular mechanisms of deep somatic pain is owed to the advancement of animal models of joint and muscular pain.57,58 However, the vast majority of these studies, and therefore the vast majority of the data about these phenomena, comes from studies of the hind limbs of small animal models. Subcutaneous pain mechanisms typically involve the tissues of the hind paw; muscular mechanisms have involved mainly the gastrocnemius and soleus muscles; joint mechanisms have mainly involved either polyarthritic models of all the tissues of the hind quarters or, in monoarthritic models, the knee and ankle joints. This led one of the leaders in the field of muscle pain mechanisms, Siegfied Mense, to title an article in 2003 as “What's different about muscle pain?”59 6. There has been a conspicuous absence of work on deep pain mechanisms from spinal (paraspinal) tissues. This leaves us with a critical question. Is what is now known about deep pain mechanism from the MSK tissues of the peripheral limbs automatically to be applied to deep pain arising from spinal tissues? Are there no important differences? If not, there is no compelling reason to hold on to theories that make the spine distinctive in any way; and there is no reason to develop animal models of spinal deep pain. So I now ask the question, “What's (or: Is there anything…) different about spinal muscular (and ligamentous) pain?”

Thankfully, there is a small but growing body of work on mechanisms of deep pain from paraspinal sources that is beginning to address this need. Chiropractic research in this area has been reviewed by Vernon 54 and Henderson. 55 A full list of chiropractic neurophysiological research is available from the Colloquium planners and is appended to this article. In addition, the works of Solomonow et al, 60-62 Indahl et al, 63 Tachihara et al, 56 and Taguchi et al 64,65 must be recognized. All of these studies are elucidating the mechanisms of deep somatic pain of axial (spinal) tissues and helping to address the question of whether there are any unique features of such pain, especially those that might underlie the distinctive clinical phenomenology of spinal pain. The early results provide encouragement for the notion that there may be distinctive features of spinal pain mechanisms and that these might explain the distinctive features of spinal pain complaints in our patients. B. Mechanical mechanisms With respect to subluxation models, the recent work on spinal loading and spinal motor control patterns deserves mention. Notable models include the following: – – – –

spinal buckling 66,67 neutral zone 68-71 ligamentomuscular reflexes 60-62,72-75 multisegmental motor control patterns

With respect to integrating the concept of ”subluxation” with more sophisticated motor control theories, an adage adapted from Korr (personal communication) is instructive: Under normal, healthy conditions, spinal segments function in a multi-segmental pattern; no segment acts alone. Under conditions of pain and injury, segments can “act alone.” Therefore, we cannot expect to restore function by having injured segments move; they must be moved to accomplish this.

The notion of segments “acting alone” means that focal pain initiates 1. ligamentomuscular reflexes altering local segmental motor control, as well as 2. somatosympathetic reflexes altering local vasoand sudomotor control (as well as distant endorgan function?). Fig 3 depicts a comprehensive model of spinal dysfunction. Note that this is not a clinical model in the

Subluxation theories

29

Fig 3.

Comprehensive model of spinal dysfunction.

style of the vertebral subluxation complex; rather, it is a predictive model that, although based upon current knowledge, identifies areas of important future laboratory and clinical work. C. Current challenges to subluxation In this final section, some of the very current challenges to the subluxation model are reviewed. For almost all of its history, chiropractic has posited that neurologic or reflex effects do result

from subluxation and that it is these effects that underscore the importance of subluxation in the health of the patient. It is this proposal—or this side of the “Arkuszewski-like” formulation with which we began this article—that received the greatest amount of criticism from opponents of the profession. Throughout this time, the mechanical side of our original formula was not overly criticized, although the concept of “misalignment” has lost most of its favor.

30 Recent developments in manipulative sciences have created a unique challenge to the very concept of a “specific mechanical problem” toward which manipulation is directed. 1. Studies on the reliability of palpation of segmental motion have reported mixed results. 76 This has led some to discard this procedure in their analysis of spinal pain. This has led others to go further and become skeptical that a “segmental mechanical problem with a disturbance of motion” actually exists. 2. A small number of studies on the validity of palpation for segmental motion or for segmental findings have reported questionable results. These studies have taken the form of randomized clinical trials of a single session of manual therapy— manipulation, 77 mobilization, 78 and manual traction 79 —in which one group receives a single palpation-specific procedure and the other group receives the same procedure at sites distant from the target segment. The immediate clinical outcomes of these studies show no significant difference between groups, calling into question the need to identify a specific segment at all. The combination of 1 and 2 led some to suggest that the whole idea of a mechanical lesion is invalid and should be discarded. 3. Recently, classification-based approaches to treatment of spinal disorders based on apparently validated prediction rules (predicting positive outcome of treatment from symptom profiles) have been developed. 80-82 Some of these either exclude or downplay the results of palpatory examination for spinal hypomobility. 80-82 On the other hand, some of them do the opposite and strongly emphasize the findings of “motion palpation” for “spinal fixation.” 83 Clinicians are now able to choose among these predictive models, with one option being to discard, or at least greatly downplay, the role of a mechanical lesion. 4. A few recent studies on healthy subjects appear to indicate that cavitations occurring during spinal manipulations are not localized to the segment putatively identified as the “lesion” and as the “target” of the maneuver. 84 This has been interpreted by some to mean that, even if a “specific mechanical lesion” does exist and even if it can be reliably identified in clinical assessment, such an exercise may be fruitless if the treatment cannot match this level of specificity.

H. Vernon The older challenge faced by the chiropractic profession was largely to the second half of our initial formulation of subluxation: “the health-deleterious effects.” Our critics have persistently questioned the premise that chiropractic subluxations caused anything more important than local, benign pain. The entire historical chiropractic project of attaching healthsignificant effects to subluxation (such as the Association of Chiropractic College's statement including the phrase that compromise neural integrity and may influence organ system function and general health) was challenged by these critics. The newer challenge is now to the first part of our statement: “A subluxation is a mechanical problem in the musculoskeletal system.…” Recent research appears to challenge this premise as well; and some, within and outside of the profession, have adopted a completely skeptical view of the entire “subluxation project.” “If it doesn't exist in the first place,” they say, “how can it have any effects? If we can't find it, why look for it and why include it in our clinical decision-making? If we can't localize our treatment to one segment, why be concerned to do so?”

Conclusion These challenges to the “subluxation concept” are in their early days and, in many instances, are based on only one or a few studies. In several instances, these studies have involved healthy subjects or those with relatively mild symptom severity. In several studies, the manual therapy intervention might be regarded as nonspecific and, therefore, would not qualify as an “adjustment.” On the other hand, critiques could be made of the quality of many of the studies that formed the basis for what might be called the “standard model” in chiropractic and the other manual therapy professions, including those which extend back several decades. Indeed, some of the modern challenges, especially in the area of manual diagnostic procedures, appear to derive precisely from the poorer quality of prior studies. The only way forward is to strengthen our efforts to investigate the “subluxation concept” with high-quality scientific studies including animal models and human clinical studies.

Funding sources and conflicts of interest No funding sources or conflicts of interest were reported for this study.

Subluxation theories

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Journal of Chiropractic Humanities (2010) 17, 33–39

Commentary

The great subluxation debate: a centrist's perspective Christopher J. Good DC, MAEd⁎ Professor, University of Bridgeport College of Chiropractic, Bridgeport, CT 06604 Received 17 June 2010; received in revised form 22 July 2010; accepted 22 July 2010 Key indexing terms: Chiropractic; Philosophy

Abstract Objective: This commentary describes the debate and some of the associated issues involving the subluxation construct. Discussion: The long-standing debate regarding the chiropractic subluxation has created substantial controversy within the profession. Currently, this phenomenon can be compared with a country with a 2-party system that has a large silent majority sitting between the 2 factions. It is argued that the position held by those in the middle (the centrists) may be the most rational view when considering all of the available evidence. It is also suggested that the subluxation construct is similar to the Santa Claus construct in that both have a factual basis as well as social utility. Ultimately, the centrists must become proactive if they want to protect the profession and further advance the evidence in regard to the subluxation. They must not only engage in the debate, but fund the research that will investigate various aspects of the subluxation and then help disseminate this evidence to fellow doctors of chiropractic, other practitioners, health care policy makers, and society at large. Conclusion: The role of subluxation in chiropractic practice, the progression of this debate, and the future of the profession will be directly determined by the role that centrists choose to play. © 2010 National University of Health Sciences.

Introduction Why does the concept of the chiropractic subluxation cause otherwise sensible people to act in irrational ways? This is a question that those within

⁎ University of Bridgeport College of Chiropractic, 75 Linden Avenue, Bridgeport, CT 06604. Cell.: +1 315 406 5842. E-mail addresses: [email protected], cgooddc@optonline. net.

and outside of the chiropractic profession have been asking almost since its inception. The divergence of chiropractors' opinions regarding the nature of joint dysfunction/subluxation can be traced back to as early as 1903 when Langworthy, Smith, and Paxson founded their own college of chiropractic in Cedar Rapids, IA. In doing so, they competed directly with Daniel David Palmer in Davenport and by 1906, they had published the first chiropractic textbook, Modernized Chiropractic.1 In this book, they describe their theory of the chiropractic subluxation as a loss of the normal field of motion. This was in contrast to

1556-3499/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.echu.2010.07.002

34 Palmer's earlier and simpler bone out of place/nerve impingement concept. 2 Since then, an array of hypotheses has been offered in regard to the chiropractic subluxation including the argument by a few that there is no evidence that subluxations exist. This latter claim is particularly curious for those of us who have spent virtually our entire lives investigating and treating the target of our manipulative care. My personal experience with chiropractic subluxation began after reading a description of chiropractic in an occupational handbook while studying as an undergraduate student. I was so fascinated that, after my prerequisites were completed, I entered Texas Chiropractic College to begin an investigation in earnest. I became exposed to a variety of new views about health and disease and, in particular, the intriguing idea that given the right neurologic circumstances, virtually anything could cause anything.3 After a year of study, I decided to continue my investigation of chiropractic at Palmer College of Chiropractic in Davenport, where the chiropractic profession first began. This exposed me to dramatically different views on subluxation theories as well as other components of the philosophy of chiropractic. Since that time, I have studied a variety of chiropractic techniques ranging from Palmer Upper Cervical Specific to Gonstead, Thompson, PierceStillwagon, and diversified. I have taken a number of seminars on commonly used techniques, including courses on extremity adjusting, Applied Kinesiology, Sacro-Occipital Technique, instrument adjusting, flexion-distraction technique, and especially motion palpation and manipulative technique from the Motion Palpation Institute. During the 27 years since my graduation, I have had the privilege of treating thousands of patients, teaching thousands of students at chiropractic colleges in both the United States and Europe, and lecturing to thousands of field practitioners. Subsequently, I believe it is fair to say that I have ended up squarely in the middle in regard to most of the profession's debates. In a word, I am a centrist. Indeed, if the surveys by McDonald 4 and the World Federation of Chiropractic 5 and writings in the recent book Chiropractic Peace 6 are any indication, it appears that I sit with the moderate majority when it comes to the political, philosophical, and scope of practice issues that surround us and especially in regard to the subluxation construct (SC). The purpose of this article is to discuss the current state of affairs regarding the SC and the role that those who occupy the middle ground, the centrists, have to play in relation to it.

C. J. Good

Discussion Why is the centrist position regarding the subluxation important? The answer may be in how a centrist perspective relates to the profession, which I believe will eventually determine our future. In a sense, the chiropractic profession is like a country with a 2-party system that also has a large, relatively silent third group of unaffiliated independent voters. Ultimately, it is the independent voters who determine the result of most elections, either actively through their vote or passively as they sit on the sidelines and watch. Consider some of the issues facing the profession. It has been argued that increasing our cultural authority is critical to our survival and success. 7,8 If this is true, then it would seem that the way forward must begin with a cultural change within the profession itself. According to Greiner, 9 organizational change typically occurs in 2 distinct ways: through evolution or revolution. On the one hand, there can be slow, steady progression stemming from relatively small, seemingly insignificant events; or alternatively, there can be a conscious, deliberate moment of dramatic and decisive action. Both processes will result in organizational change, and this often occurs when those who sit at the ends of a debate spectrum convince enough in the middle to move in their particular direction. Alternatively, sometimes, those in the middle ignore the arguments from both sides and wait for a third option, especially when they are convinced that neither group is worthy of joining. I feel that this is the same situation regarding the SC and as a profession, we are coming to a point in time where we must make a choice from a menu of 3 items. On one hand, we can cling to traditional notions about the SC and the suspect baggage associated with it. On the other hand, we can let the construct fade away along with other remnants of our past. Thirdly, we can continue to accept the SC as a core component of the profession and investigate and explain it in a transparent, honest, and evidencedbased fashion. I have witnessed similar transformations made with other elements of our professional culture, and I would offer the concept of vitalism as an example. Although undoubtedly there are at least a few members of the profession who privately embrace a vitalistic concept, it appears that there are fewer still who publicly use Universal and Innate Intelligence as an explanation for the results obtained under chiropractic care. A reasonable alternative to vitalism has been offered by Mootz whereby these concepts are coined the Chiropractic Metaphor and are recast as

Subluxation a centrist’s perspective homeostasis. The supernatural component is left as a historical anachronism that no longer needs to play a role in contemporary practice. 10 Building on this, I propose that vitalism and its godly implications can be set aside and replaced by the concept of vitality. Essentially, this is defined as the natural capacity a living thing has to live and thrive. The discussion then becomes focused on which clinical interventions we as practitioners can offer that help patients regain their health and achieve their optimal potential given their level of vitality. Similarly, there are forces at work trying to affect a paradigm shift regarding the SC that I believe will result in a referendum that will be determined by the 3 groups of voters. On one end of the ballot is the petition for the eradication of the word subluxation from the profession's lexicon (but not necessarily the concept) 11 and/or against its very existence. 12 I would characterize this view as being fomented by a small group that might best be referred to as hypercritical evidentialistas. This group demands scientific proof, offering their version of the truth in various types of nonexperimental publications. Upon closer inspection, this can be exposed as a selective interpretation of some of the available evidence. 13 Invariably, this faction crosses swords with a small group of those at the other end of the spectrum, the loyal adversaries who might be referred to as uncritical observationalists. This group holds the SC as a sacred cow, often giving it quasireligious attributes. 14 Within this camp, chiropractors play a priestly role demonizing subluxation as the scourge of health that must be exorcised at every available opportunity through the adjustment. I suggest that these 2 groups sit at the extremes of our profession and may be blinded by their own agendas, beliefs, and intense dislike for each other. In particular, they are unable to perform a dispassionate review of the available evidence regarding the SC. In my opinion, it is the centrists, playing the role of the rational empiricists, who occupy the middle ground and who have the best perspective in regard to interpreting the evidence of the subluxation's existence and the extent to which it may creates “nerve interference.” It is also my observation that the centrist group is composed of more than just those known as middle scope chiropractors, 4 but also includes a large number of those previously identified as narrow scope and broad scope. In the introduction to Chiropractic Peace, this concept is discussed at length by McDonald and Strang who point out that, despite classifying DCs into 3 camps, when it comes to the subluxation and the breadth of conditions treated with manipulative care,

35 the vast majority of chiropractors share the beliefs that the SC exists, they do not want to discontinue using the term, and they will treat some nonmusculoskeletal conditions with adjustments. 6 Later in this same book, Ashley E. Cleveland's essay “Walking a Middle Path to Peace” further describes the centrist's perspective when she offers a balanced view of some of the traditional principles of chiropractic. This includes regarding patients as self-regulating organisms capable of adaptation, understanding the substantial impact that dysfunction of the musculoskeletal system has on health, and the commitment that we have to care for the whole person and not simply his or her parts.

The centrist perspective and the SC In terms of the SC, centrists have as their cornerstone the clinical reality of the “painful sticky joint” that, in essence, may be our layperson's description of a mild facet joint syndrome. This concept is well described within our contemporary texts, 15-18 but the reality of its existence is essentially based upon the published evidence combined with the personal clinical experiences chiropractors have had as both a patient and a doctor. The centrist perspective of the construct is broader than this though and extends to many possibilities of motion segment dysfunction, from the clinically unstable “orthopedic subluxation” to the completely fixated motion segment as a result of bony ankylosis or congenital fusion. This model encompasses the functional, structural, and pathoanatomical changes to the various components of a spinal motion segment as well as the other pelvic and peripheral motion segments. Therefore, in terms of a working definition of the SC, centrists are comfortable with the Association of Chiropractic Colleges presidents' definition of subluxation 19 and may be equally as comfortable with the consensus definition proposed by Gatterman and Hansen20 because, essentially, they say the same thing: a subluxation is a change in joint motion that affects the nervous system. Centrists are comfortable with the ambiguity of these definitions because they recognize the strength of words that are broad and inclusive. They recognize that even though the definitions are unsuitable as the basis for a research endeavor, they are a work in an evolutionary process that leaves the clinical door open for patients with any manner of articular problem to enter their offices and be cared for. In regard to subluxation causing nerve interference, centrists recognize that it is an antiquated

36 term that is more appropriately recast as neural reactivity. Essentially it is the appreciation that many of the signs and symptoms associated with motion segment dysfunction are likely the result of reactions to mechanical or chemical insults to neural tissue or, more commonly, through reflexes generated within the nervous system as a result of nociceptor or proprioceptor activity initiated in the tissues comprising the motion segment. As for evidence-based health care, certainly, the peer-reviewed journals stand at the top of the list as sources of important information; but centrists read these understanding that they only provide a narrowly focused glimpse of the subject at hand and that each research study has its own strengths and limitations. Even a well-written systematic review or meta-analysis is a selective interpretation of the accessed literature, and these will be written based on the criteria and biases the authors bring to the study. Therefore, in addition to the peer-reviewed journals, centrists recognize that the other critically important source of literature would include the profession's most recent textbooks. In this case, it is within our textbooks that the depth and breadth of a well-evidenced contemporary perspective of the SC are available. Indeed, the current chiropractic textbooks are of excellent quality and are founded on the best available evidence that existed just before the point of publication. Of course, journal articles help fill the void regarding more recent advances; but a true contemporary understanding of the SC includes both textbooks and journal publications. In addition to the published literature, centrists are pragmatic and recognize the importance of clinical observation and patient values, which completes the evidence-based practice triad. Centrists essentially are open-minded yet skeptical practitioners attempting to do what is best for their patients. They have an interest in reading about the newest research findings in regard to the SC, however, they are struck by how little we have evidenced than by the meager evidence itself. This is primarily because as they earnestly treat the human condition, they recognize that only a sliver of what they have observed in clinical practice has yet to be studied in any detailed fashion and this is primarily because of the limitations of most of the clinical studies that chiropractors have been involved in. Certainly, a growing number of randomized clinical trials exist evidencing the benefits of manipulation for various types of spinal pain.21 But a shortcoming of most of these is that they failed to report on the changes in subluxation/joint dysfunction pre- and posttreatment while other outcomes were being measured. This is not

C. J. Good to say that the clinicians did not analyze the motion segments first to determine the target area of their treatment, it is that the subluxation data were not analyzed and published, and this is particularly lamentable. Therefore, regarding investigating the subluxation clinically, most of this has occurred in conditions not involving low back pain, neck pain, or headaches, and has typically appeared as part of a case study publication. Given the hierarchy of evidence, case studies sit near the bottom and are seldom included when considering the evidence regarding the SC. 22 Yet centrists will not dismiss case reports as having absolutely no value especially because they have witnessed many positive clinical responses that are not satisfactorily explained by the competing hypotheses. Hartman 23 has ruefully pointed out that a number of alternative mechanisms could be at work when patients appear to improve under care, and these have nothing to do with the effectiveness of the treatment itself. Included in this list are the placebo effect, the self-limiting nature of the disease, regression toward the mean, the effect of known or unknown cotreatments, and/or reporting biases of the patient or the doctor. Centrists accept that these phenomena could be at work, but they also realize that one important possibility is that there truly was a treatment effect from their adjustment of the patient's subluxation. In terms of the SC, possibility rises to the level of probability as the presenting complaint mirrors the signs and symptoms associated with the painful sticky joint or even one of the more complex musculoskeletal subluxation syndromes identified by Gatterman 17 and patients respond to treatment with dramatic and immediate responses. One might ask why it is that these musculoskeletal clinical conditions actually form the basis for the centrist perspective in regard to the SC instead of broadening this to include nonmusculoskeletal conditions. Firstly, chiropractors treat patients with musculoskeletal pain approximately 90% of the time 24,25 ; and painful subluxations are simply encountered in their offices as one of the most common causes of musculoskeletal pain. This has been documented by Smith and Carber 26 when DCs were surveyed about their perspectives on subluxation. They found that more than 75% of chiropractors' clinical approach to addressing musculoskeletal or biomechanical disorders such as back pain was “subluxation based.” Secondly, I suggest that there is another important criterion related to the causation of disease: temporality. 27,28 The clinical observations that chiropractors make either as patients themselves or as

Subluxation a centrist’s perspective doctors rendering care and the dramatic results obtained immediately after analysis and adjustment at the site of the lesion tip the scales of belief. Positive clinical responses in acute, subacute, and even chronic cases are occurring within seconds and minutes, not hours, days, weeks, or months; and it is this evidence that causes centrists to shake their heads when the existence of subluxation is questioned. These repeated observations have convinced the doctors beyond all reasonable doubt that segmental dysfunction exists and that they have the means for treating it. To centrists, the SC is simply the most rational model used to explain the clinical observations that occur daily and thousands of times per year in their patients. Essentially, centrists recognize that clinical anecdote, expert opinion, and the case reports, which eventually flow from these observations, are acceptable forms of evidence that must be considered along with all other evidence if one is truly going to consider the best available evidence. Naturally, one must be ever mindful of the shortcomings of clinical observations and continue to look for evidence that falsifies these hypotheses if one is truly a practitioner-scientist. But this is one of the strengths of the centrist position: to date, there has been no compelling falsification of the joint dysfunction hypothesis. It is granted that some of the earlier hypotheses regarding nerve impingement have been debunked. But even the claims that the reliability studies investigating the diagnostic tools used to identify the manipulative lesion are wanting or that the validity studies are too sparse do not falsify the SC. They only inform the debate and help create the demand for better research. For the time being, the chiropractic subluxation is the most credible reason to explain the clinical results obtained in these patients, which is primarily why centrists will not abandon the SC, much to the chagrin of the evidentialistas. In a similar sense, the same can be said for some nonmusculoskeletal cases. Centrists are particularly skeptical of visceral conditions being caused by subluxation, which is particularly irksome to the uncritical observationalists in the profession who view subluxations as being far more involved in these. In this case, Smith and Carber 26 found that most chiropractors reported that less than 20% of their clinical approach was “subluxation based” for patient complaints deemed to be principally problems with circulation, digestion, or similarly “visceral” in nature. Centrists recognize that subluxation could often present as a condition that mimics a visceral condition and in fact no true visceral disease exists, 18 such as in the case of pseudoangina. 29 Centrists however also view

37 treatment of some selected nonmusculoskeletal conditions as simply a therapeutic trial that patients have a right to choose to participate in. Given that proper clinical procedures (including informed consent) have been followed and given consideration for the current state of the evidence, there truly is no compelling reason to refuse chiropractic management (including manipulative care) for these conditions if patients decide they want it. Ultimately, though, I would suggest that beyond the clinical reality of subluxation, it is the social utility of the construct that has caused it to remain as a cornerstone of the profession. In this sense, it is reminiscent of a similar cultural phenomenon, namely, the Santa Claus construct (SCC).

The SC and the SCC How can the SC be compared with Santa Claus? In both cases, a contemporary perspective that combines the best available evidence with critical analysis leads one to conclude that there are elements of truth, fiction, and cultural utility that ultimately make both constructs important and useful. In the case of the SCC, it is very likely that a person known as Saint Nicholas actually existed. According to historical accounts he was Greek by birth; became bishop of Myra; and died on or about December 6, 346 AD. He also gained a reputation for secretive gift giving and became the model for the modern-day mythical figure of Santa Claus. 30,31 The modern permutation of the SCC involves all sorts of fictional additions. Depending on which story one encounters this may include Santa and the elves living at the North Pole building toys each year for welldeserving children. Santa Claus then travels around the world in a single night on a flying sleigh led by a brightly nosed reindeer named Rudolph to deliver these gifts. “Evidence” of his existence abounds, as he can be seen in countless parades and malls in person and on television. Of course, as children grow up, they realize the impossibility of such feats and observe the lack of consistency between the imposters who claim to be Santa. Yet, nonetheless, the joyful results of gift giving, the sharing of traditions, and the creation of lifelong memories are positive reinforcements that maintain the SCC as a core feature of modern Western civilization. Similarly, the SC begins with an element of truth: that abnormal motion of joints exists and this may cause pain and other reactions in the nervous system. Historically, an early observation of this can be traced back 2500 years ago in Greece with writings attributed

38 to Hippocrates that noted the localized physical findings associated with joint pain and described the manipulation of them. 16 In 1746, Hieronymus defined the modern term and described it as having “lessened motion, slight changes of position of articulating bones and pain.…” 17 The advent of technology in the form of diagnostic imaging has allowed the visualization of severe misalignments associated with motion segment dysfunction to be observed, and these range from traumatically induced subluxations (ie, the orthopedic subluxation or partial dislocation) to regional distortions associated with scoliosis or acquired postural changes and to smaller amounts of misalignment as indications of spinal instability or facet syndromes. Other types of joint dysfunction may be evaluated with video fluoroscopy studies and on stress film analysis. 15,17 More recently, there have even been magnetic resonance imaging studies establishing changes in spinal motion as assessed with motion palpation or patient movements. 32 Studies focusing on static palpation and motion palpation have reported varying degrees of reliability and validity, and a compendium of these can be found in Bergmann and Peterson's text Chiropractic Technique.15 It is important to remember however that one of the important observations about these studies is the consistent lack of methodological rigor. Nevertheless, evidentialistas do not seem to recognize the weakness of their arguments when opining about the lack of reliable and/or valid subluxation detection tools in that it is not possible to make any strong conclusions about studies with such limitations. What one can say about these studies is that a large number of investigations have occurred, many with poor methodology; and overall, there are very mixed results. Ultimately the published evidence regarding the SC remains a work in progress. More so given the current state of technology, how can one truly establish the very small reductions of motion associated with muscular or ligamentous restrictions as proposed by Gillet and Liekens33 or the loss of “endfeel” and “joint play” as proposed by Mennel? 34 This is where centrists ask themselves the ultimate pragmatic question: are the limitations of the current published evidence enough to justify dismissing the SC from clinical practice? Would this truly benefit patients and society? I would offer that the answer to this question is a resounding “no.” This is not because of the inability to let go of a cherished dogmatic belief or because of a financial stake in private practice. It is because centrists are willing to wager their professional reputations (and indeed the future of chiropractic) on an entity that they are

C. J. Good convinced will become well evidenced as the technologies and the scientific rigor of the investigations improve, no matter who does the research. It is not the existence of Santa Claus they are betting on; it is the existence of Saint Nicholas and the impact he has had on society that they are convinced of. They are willing to wager that, at the very least, painful sticky joints exist essentially because the weight of all the evidence convinces them. This includes the published evidence to date plus the immediate responses to thousands of people over years of practice. And most persuasively, they have had a painful subluxation adjusted and felt the immediate dramatic result in themselves. Centrists are very comfortable waiting for science to add more to the growing pile of evidence while they go about the business of successfully changing lives one patient at a time. However, I suggest that simply waiting for someone to create the evidence will not change the current difficult situation and centrists need to understand this and take action themselves. In my view, if the chiropractic profession is truly going to move forward in regard to the SC, only a proactive role by the centrists will accomplish this. We must become vocal about directing our research initiatives to include a focus on various aspects of the SC. And we must also fund this. Then as the evidence accumulates, we must share this with ourselves, other practitioners, health policy makers, and society at large. To sit by idly and hope that this is accomplished without the centrists will only allow those at the fringes to continue their destructive ways and continue to allow the profession to evolve into an entity that does not represent the majority.

Conclusion It is suggested that centrists comprise the moderate majority of chiropractors who are convinced by the available evidence that the contemporary model of the SC is legitimate and useful, especially in regard to painful articular conditions and their sequela. They also view treatment of subluxation for some selected nonmusculoskeletal conditions simply as a therapeutic trial that patients have a right to choose to participate in. Despite the opinions of small vocal minorities to either side, it is this broad middle group that sustains the profession and gives it the greatest opportunity for continued success. Ultimately, to have a profession that is highly skilled at identifying and treating localized

Subluxation a centrist’s perspective motion segment dysfunctions with manual therapy and other conservative care interventions serves the best interests of society, especially those whose lives are affected by symptomatic lesions in need of this type of care. If the chiropractic profession is to survive and flourish, the centrists should rise up and lead this profession before the extremist groups at its fringes catalyze its destruction.

References 1. Johnson C. Modernized chiropractic reconsidered: beyond foot-on-hose and bones-out-of-place. J Manipulative Physiol Ther 2006;29(4):253-4. 2. Gibbons RW. Solon Massey Langworthy: keeper of the flames during the “lost years” of chiropractic. Chiro Hist 1981;1: 15-21. 3. Harper WD. Anything can cause anything; 1974 (published by the author, Seabrook, TX). 4. McDonald WP, editor. How chiropractors think and practice. Ohio Northern University: Institute for Social Research; 2003, 15-21,45-86. 5. World Federation of Chiropractic [Internet]. Consultation on the identity of the chiropractic profession. [cited 2010 June 9]. Available at: http://www.wfc.org/website/index.php?option= com_content&view=category&layout=blog&id=64&Itemid= 93&lang=en. 6. McDonald WP, editor. Chiropractic peace. Bloomington (Ind): Trafford Publishing; 2009, 1-21, 67-106. 7. Keating J, Hyde TE, Menke JM Seaman D, Vincent RE. In quest for cultural authority. Dyn Chiropr 2004;22(26). Available at: http://www.dynamicchiropractic.com/mpacms/ dc/article.php?id=46556. 8. Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiro Osteo 2008; 16(10). 9. Greiner LE. Evolution and revolution as organizations grow. Harv Bus Rev 1972;50(4):37-46. 10. Mootz R. Art, science and philosophy: enthusiasm and the untestable. J Manip Physiol Ther 1992;15(8):542-5. 11. Winterstein J. It is time to think in different terms: re-considering subluxation. J Chiro Med 2003;2(4):134-6. 12. Mirtz TA, Morgan L, Wyatt LH, Greene L. An epidemiological examination of the subluxation construct using Hill's criteria of causation. Chirop Osteoporos 2009;17(13). 13. Good C. A criticism of an epidemiological examination of the subluxation construct using Hill's criteria of causation: limitations, suspect conclusions and an opportunity missed. Chirop Osteoporos 2010. Available at: http://www.chiroandosteo.com/ content/17/1/13/comments#404659.

39 14. Foundation for vertebral subluxation [Internet]. Kennesaw, Georgia. Cited 2010 Jun 10. Available at: http://vertebral subluxation.health.officelive.com/policy.aspx. 15. Peterson D, Bergmann T. Chiropractic technique. Elsevier; 2011, 89-90, 74-79, 429-40. 16. Haldeman S, editor. Principles and practice of chiropractic. McGraw-Hill; 2005, 368-70, 441, 956-7. 17. Gatterman MI. Foundations of chiropractic: subluxation. Elsevier-Mosby: 2005, 115-132, 168-190. 18. Leach RA. The chiropractic theories: a textbook of scientific research. Lippincott: Williams and Wilkins; 2004. p. 301. 19. Association of Chiropractic College. A position paper on chiropractic. J Manip Physiol Ther 1996;19:634-7. 20. Gatterman M, Hansen D. Chiropractic nomenclature. J Manip Physiol Ther 1994;17(5):302-9. 21. Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chirop Osteoporos 2010;18(3). 22. Centre for Evidenced Based Medicine Levels of Evidence [Internet]. Accessed June 12, 2010. Available at: http://www. cebm.net/index.aspx?o=5653. 23. Hartman SE. Why do ineffective treatments seem helpful? A brief review. Chirop Osteoporos 2009;17(10). 24. Leboeuf-Yde C, Pedersen EN, Bryner P, Cosman D, Hayek R, Meeker WC, et al. Self-reported non-musculoskeletal responses to chiropractic intervention: a multination survey. J Manipulative Physiol Ther 2005;28(5):294-302. 25. Hawk C, Long CR, Boulanger KT. Prevalence of nonmusculoskeletal complaints in chiropractic practice: report from a practice-based research program. J Manip Physiol Ther 2001;24(3):157-69. 26. Smith M, Carber LA. Survey of US chiropractor attitudes and behaviors about subluxation. J Chiropr Hum 2008:19-26. 27. Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965;58:295-300. 28. Ward AC. The role of causal criteria in causal inferences: Bradford Hill's aspects of association. Epidemiol Perspect Innov 2009;6:2. 29. Wax CM, Abend DS, Pearson RH. Chest pain and the role of somatic dysfunction. JAOA 1997;97(6):347-55. 30. Cunningham L. A brief history of saints. Hoboken, NJ: WileyBlackwell; 2005. p. 33. 31. Jones CW. Saint Nicholas of Myra, Bari, and Manhattan: biography of a legend. Chicago: University of Chicago Press; 1978. p. 7-13. 32. Kulig K, Powers CM, Landel RF, Chen H, Fredericson M, Guillet M, et al. Segmental lumbar mobility in individuals with low back pain: in vivo assessment during manual and self imposed motion using dynamic MRI. BMC Musculoskelet Disord 2007;8(8). 33. Gillet H, Liekens M. Belgian chiropractic research notes. Huntington Beach, CA: Motion Palpation Institute; 1984. 34. Menell JMcM. Joint pain: diagnosis and treatment using manipulative techniques. Boston: Little, Brown and Co; 1964.

Journal of Chiropractic Humanities (2010) 17, 40–46

Commentary

Implications and limitations of appropriateness studies for chiropractic James M. Whedon DC a,⁎, Matthew A. Davis DC, MPH a , Reed B. Phillips DC, PhD b a b

Instructor, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH President Emeritus, Southern California University of Health Sciences, Whittier, CA

Received 21 September 2010; received in revised form 12 October 2010; accepted 13 October 2010 Key indexing terms: Chiropractic; Disease management; Utilization; Small area analysis

Abstract Objective: The appropriate role for chiropractic in US health care has not been established, but third-party payors and public policy makers must make decisions about the appropriate role for chiropractors in health care systems and for the services that chiropractors provide. Appropriateness studies for chiropractic may inform those decisions. The purpose of this article is to discuss the implications and limitations of appropriateness studies for chiropractic. Discussion: We reviewed the general context for assessment of the appropriateness and the application of appropriateness studies to chiropractic in particular. We evaluated the implications and limitations for chiropractic of methods of small area analysis and the RAND-UCLA Appropriateness Method. The RAND-UCLA Appropriateness Method has been applied to the evaluation of spinal manipulation. Regional variations in chiropractic utilization have yet to be described through small area analysis, but these methods appear to hold some potential for assessing the appropriateness of chiropractic care. Both small area analysis and the RAND-UCLA method offer limited possibilities for the assessment of chiropractic appropriateness. Conclusion: Future assessment of the appropriate role for chiropractic in US health care will raise issues beyond the scope of previous appropriateness studies. Studying the appropriate role for chiropractic will require consideration of the clinical discipline in its entirety, rather than individual consideration of specific interventions. A fair assessment of chiropractic appropriateness will require new evidence and perhaps new research methodologies. © 2010 National University of Health Sciences.

Introduction ⁎ Corresponding author. 30 Lafayette St., Lebanon, NH 03766. Tel.: +1 603 653 3247; fax: +1 603 653 3201. E-mail address: [email protected] (J. M. Whedon).

The delivery of health care services in the United States is characterized by geographic variations that cannot be justified scientifically. 1 Consequently, many assumptions about the quality of US health care and the

1556-3499/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.echu.2010.10.001

Commentary appropriateness of health care interventions are being challenged.2 Clinicians and their patients must decide what kind of care is best, whereas health policy decision makers and third-party payors are faced with the considerable challenge of determining the appropriateness of various interventions. The chiropractic profession is the third largest portal-of-entry health profession in the United States (after medicine and dentistry), 3,4 but the appropriate role for chiropractic in the United States has not been established. The role of chiropractic has been explored from both a biomedical and a sociological perspective, 5-7 but the profession has failed to establish a coherent vision of purpose. 6 Amid this context of uncertainty, third-party payors and public policy makers must make decisions about the appropriate role for chiropractors in health care systems and for the clinical services that chiropractors provide. Research on the appropriateness of chiropractic care may help inform their decisions. The purpose of this article is to discuss the implications and limitations of chiropractic-related appropriateness studies.

41 chiropractic describe the profession as a whole health system. This is how the profession is viewed by most chiropractors themselves and by many patients. 5,24 If chiropractic is a whole health system, then its appropriateness should be measured not only by the efficacy of a single intervention but by the effectiveness of the entire chiropractic clinical encounter. 25 With increasing interest in the integration of medical and nonmedical health professions, it may prove helpful to rigorously assess the appropriateness of general chiropractic care. Decisions about inclusion in integrative clinics and health plans may be made on the basis of professional identity rather than solely on the services provided. The appropriateness of chiropractic care in general is therefore relevant to decisions regarding inclusion of doctors of chiropractic. However, the double standard inherent in this argument must be acknowledged. Published studies on the appropriateness of medical interventions appear to have been grounded on the tacit premise that inclusion of conventional medicine in health care is appropriate. As a nondominant profession in the health care environment, the chiropractic profession is not always afforded the same presumptive status.

Discussion The 1998 editorial in The New England Journal of Medicine posed the question, “What role for chiropractic in health care?”7 Paul Shekelle, author of numerous articles on the appropriateness of health care interventions, considered the question of whether chiropractic should be considered a nonsurgical specialty or an alternative to medicine. Following his review of the evidence, he concluded that chiropractic provides limited benefits for musculoskeletal conditions, but use of chiropractic as a broad-based alternative to medical care is inappropriate. After another decade of chiropractic research activity, that answer may still ring true, but the questions have changed. Nearly 70% of chiropractors reject the characterization of chiropractic as alternative medicine. 8 Spinal manipulation, the intervention most commonly used by chiropractors, is now of proven clinical value for treatment of certain conditions. 9-16 Despite efforts toward integration, however,17,18 the future role of chiropractic in US health care remains uncertain.6 Since the RAND Corporation studies on the appropriateness of spinal manipulation were published in the 1990s,19-23 the appropriateness of chiropractic care has not been rigorously investigated. However, the RAND studies focused on spinal manipulation, not chiropractic as a whole. Sociological studies of

Assessment of the appropriateness of health care services Appropriate care is care that is worth providing and that has a favorable risk-benefit ratio. 26 Assessments of appropriateness can inform public policy and thirdparty reimbursement as well as provider and patient decision making. Research methodologies relevant to the study of appropriateness include small area analysis and the RAND-UCLA Appropriateness Method. Small area analysis techniques allow researchers to describe and map geographic variations in health care utilization, describe patterns in variation, and identify variables that may in part explain the variation. 27,28 The RAND-UCLA Appropriateness Method is an established means of assessing the appropriateness of a health care intervention. 26 In this method, a literature review is performed to create a list of clinical indications for using a particular procedure. Members of a panel of experts critically review and synthesize the evidence to generate quantitative estimates of the benefits and harms, and independently rate the appropriateness of performing the procedure for each indication. The panel members subsequently meet, discuss areas of disagreement, and again independently rate the indications. A mean appropriateness score for each intervention is then calculated from the collective

42 results. 29 Criteria resulting from the application of this method can be used to retrospectively rank the appropriateness of interventions. Appropriateness criteria can be used to inform clinical decision making, 30 but are probably more useful for health policy decision making. 31 The RAND-UCLA Appropriateness Method was developed in part to help answer questions about appropriateness that were originally raised by studies conducted by John Wennberg. In 1973, Wennberg and Gittelsohn 32 published the first in a series of studies that described unexplained geographic variations in medical care. Since then, The Dartmouth Atlas of Health Care Project, using methods of small area analysis that define local health care markets, has examined differences in per capita resource inputs and utilization of various medical and surgical services. 27,33,34 This research has uncovered differences in the distribution and use of health care services in 306 hospital referral regions across the United States—health care spending by Medicare enrollees varies by as much as 2.5-fold among regions. 35 Many such variations are likely to be inappropriate if they cannot be adequately explained on the basis of differences among regions in illness rates or sociodemographic characteristics. 36,37 Geographic variations in medical spending have been found to be due to differences in the number of physician visits (particularly inpatient physician visits), medical procedures, and use of specialty medical services. 35 Interestingly, areas of higher medical spending (often referred to as high practice intensity areas) do not appear to have better health care outcomes or higher levels of patient satisfaction. 38,39 To explain the geographic variations in medical spending, The Dartmouth Atlas of Health Care classifies health care services into 3 categories of variation: • Supply-sensitive care (63% of care) • Effective care (12% of care) • Preference-sensitive care (25% of care)40 Supply-sensitive care is governed by the local supply of health care services: the greater the supply, the higher the rate of use. Higher rates of use of supplysensitive care however may not confer better health outcomes. 40 Effective care is appropriate care; it consists of health care services that are proven effective and have a favorable risk-benefit ratio. Failure to treat an eligible patient with effective care represents underuse. 40 An example of effective care is surgical fixation of a severe open comminuted tibia fracture in an otherwise healthy patient. Preference-sensitive care

Commentary includes services for which the pros and cons are subject to interpretation; in these cases, when the best choice of care is not clear-cut, patients should be given the information and support they require to share in the decision making. 41 Nonspecific low back pain is an example of a condition that may be subject to preference-sensitive care. In such cases, the choice should be based on the patient's own preferences; but all too often, it is the provider who decides. 40

Implications of appropriateness studies for chiropractic Both small area analysis and the RAND-UCLA Appropriateness Method have implications relevant to the assessment of chiropractic appropriateness, and the RAND method has been applied to the evaluation of spinal manipulation. 19-23 As the United States struggles with health care reform, the concept of the appropriateness of medical interventions is receiving attention from policy makers. Officials at the highest levels of the federal government recognize that unwarranted variations in medical utilization and spending are well documented 42 and that it may be possible to control ballooning health care costs by correcting the overuse, underuse, and misuse of medical care. 43 Within this context, questions about the appropriateness of chiropractic care may also be raised. Decision makers who know that more health care does not necessarily mean better care may ask, “For which patients is chiropractic care appropriate and for what indications and purpose?” The assessment of appropriateness, whether applied to medicine, chiropractic, or any other clinical discipline or intervention, is a subjective determination that should draw upon objective evidence for effectiveness, safety, and cost. The manner in which clinical decision making occurs also bears upon the appropriateness of care. Without the participation of the patient, the very idea of judging one approach to care as being more appropriate than another might be rightly perceived as high-handed. Decisions about the utilization of health care services must take into account the individualized needs and preferences of the patient and should not be driven by the needs, inclinations, or specialized expertise of the doctor. The sharing of clinical decision-making between doctor and patient is thought to help facilitate the delivery of appropriate care. 44,45 Fig 1 illustrates the interplay of 4 principal factors involved in the assessment of appropriateness.

Commentary

43 use of spinal manipulation to be appropriate in 46% of cases and inappropriate in 29%. The assessment was inconclusive in 25% of cases. For cases in which the patient received chiropractic care but did not receive spinal manipulation, the investigators found that manipulation would have been appropriate in 38%.23 A similar set of appropriateness ratings was developed for manipulation and mobilization of the cervical spine.20 Potential implications of small area analysis

Fig 1. Interplay of the 4 principal factors involved in the assessment of appropriateness.

Implications of the RAND-UCLA Appropriateness Method In a series of studies in the 1990s, the RAND-UCLA Appropriateness Method was applied to the evaluation of spinal manipulation for neck and low back pain. 19-23 Two different appropriateness studies were conducted on spinal manipulation for low back pain. The first study convened a multidisciplinary panel, including chiropractic physicians, medical doctors, and an osteopathic physician. Of 1550 indications for spinal manipulation, the panel found 60% to be inappropriate, 30% equivocal, and 7% appropriate. 22 The second study convened an all-chiropractic panel, which found that of 1570 indications, 48% were inappropriate, 25% uncertain, and 27% appropriate. 21 The authors noted that, “the large number (48%) of indications felt to be inappropriate probably reflects our attempt to make exhaustive the list of potential indications for performing spinal manipulation.”21 In both panels, the indications deemed appropriate included the more common presentations of back pain, whereas the inappropriate indications contained many uncommon presentations. Ratings varied significantly among panel members; chiropractors were more likely to rate clinical indications as appropriate for manipulation than were nonchiropractors. 19 A retrospective review of chiropractic office records was subsequently conducted to determine the appropriateness of the use of spinal manipulation for low back pain using the 9-point scale criteria. The study found the

Regional variations in chiropractic utilization have yet to be described through small area analysis. These methods have not been applied to the study of chiropractic appropriateness. However, consideration of the concepts of supply-sensitive care, effective care, and preference-sensitive care may aid the formulation of hypotheses regarding the appropriateness of chiropractic care. Overutilization of supply-sensitive care occurs when care is rendered in proportion to increased availability rather than clinical necessity. 36 A 2008 study found evidence of oversupply of chiropractic services in a market of questionable demand in Ontario, Canada. 46 Another study that examined the national supply and demand of US chiropractors uncovered a 28% decrease in the national supply of new chiropractic college graduates, whereas national expenditures on chiropractic care grew significantly over the same period.3 Chiropractic care may be supply-sensitive in certain geographic areas. By contrast, systematic underutilization of effective care occurs when services of proven value for which the benefits outweigh the risks are underused because of lack of support for systematic compliance with treatment guidelines. 36 Spinal manipulation is generally considered to be a safe, 13,47 effective, 10-13,15 and cost-effective48 treatment of certain spinal pain disorders; and the number of individuals with such spinal pain disorders appears to greatly exceed the current number of chiropractic users. 3,49,50 However, many of the studies that have demonstrated the effectiveness of spinal manipulation for spinal pain disorders have not shown outcomes significantly better than other therapies, although patients do often report high levels of satisfaction. 47,51,52 Spinal manipulation for certain spinal pain disorders therefore may be considered to fall under the category of preferencesensitive care. The category of variation for a given intervention may depend upon the condition being treated, patient-related variables, and other factors; and considerable overlap between categories may occur for any given procedure.

44 A conspicuous geographic variation in the delivery of chiropractic care was recently revealed by analysis of the Medicare Chiropractic Services Demonstration, which was intended to evaluate the effects of expanded coverage for chiropractic services. 53 Despite reduced costs in 4 of 5 demonstration areas, a budget neutrality analysis found a net increase in overall Medicare payments in demonstration areas as compared with control areas. The increase in payments was due to increased utilization in the Chicago area. This finding suggests the possibility that care delivered in the Chicago demonstration site may have been supply sensitive. Limitations of appropriateness studies for chiropractic The RAND-UCLA method addresses the appropriateness of initiating treatment, but not of frequency or duration of treatment, issues of particular relevance to chiropractic care, which is characterized by serial treatments. 54 Furthermore, the RAND-UCLA method is intervention and condition based; and therefore, although applicable to the evaluation of an intervention (ie, spinal manipulation) for the care of a disorder (ie, low back pain), it is not designed to evaluate a complex clinical encounter. Therefore, the RAND-UCLA method may be unsuited to evaluate the appropriateness of chiropractic care in general. Chiropractic care includes but is not limited to spinal manipulation, so it would be erroneous to equate the appropriateness of the common domain procedure of spinal manipulation with the appropriateness of chiropractic health care. A typical chiropractic clinical encounter may include (in addition to or instead of spinal manipulation) physical therapy modalities and patient counseling on diet, nutritional supplementation, exercise, and lifestyle modification. 55 Methods of small area analysis used to investigate geographic variations in medical care could be applied to the study of chiropractic care. Any analysis of Medicare claims for chiropractic, however, must be interpreted in light of Medicare's restrictive reimbursement policies. Medicare dictates that the primary diagnosis must be a “vertebral subluxation” and the secondary diagnosis must be a related neuromusculoskeletal condition, and the only reimbursable treatment procedure is spinal manipulation. Medicare claims data thus effectively equate chiropractic care with spinal manipulation for neuromusculoskeletal conditions related to spinal dysfunction, and inferences regarding the appropriateness of spinal manipulation may not be generalized to chiropractic in general.

Commentary In and of themselves, both small area analysis and the RAND-UCLA method offer limited possibilities for the assessment of chiropractic appropriateness. Small area analysis of Medicare claims offers great potential for descriptive studies and may also be used to help explain variations in chiropractic utilization. For example, geographic variations in the provision of services may be related to variations in state scope of practice laws or patient demographics. However, any attempt to analyze the appropriateness of chiropractic care in general would be limited by Medicare's restrictive inclusion and reimbursement policies. If applied to a less restrictive source of data, techniques of small area analysis might have greater potential; but Medicare claims are currently the single most comprehensive source of clinical data available in the United States. The RAND-UCLA method is similarly limited because it was designed to evaluate interventions, but not a clinical encounter in its entirety. Furthermore, the expert opinion generated by the RAND-UCLA method is probably more applicable to the evaluation of interventions for which there is little evidence, and may be regarded as superfluous if applied to interventions for which systematic reviews and clinical practice guidelines are already available. Finally, scant evidence is available for assessing the appropriate role for chiropractic care in general as a complex clinical encounter. 24 The personalized, patient-centered paradigm of chiropractic care and the wide variation in chiropractic techniques and practice styles present challenges for appropriateness research. 54,56,57 It may be necessary to use new methods to evaluate the appropriateness of chiropractic as a whole health system.24,58

Conclusion The appropriate role for chiropractic in US health care has yet to be determined. This article discussed the relevance of appropriateness studies, methodologies used to assess appropriateness, and identified implications and limitations of those approaches for the evaluation of chiropractic care. The future assessment of the appropriate role for chiropractic in US health care will raise issues beyond the scope of previous appropriateness studies. Studying the appropriate role for chiropractic will require consideration of the clinical discipline in its entirety, rather than individual consideration of specific interventions. A fair assessment will require new evidence, and perhaps new

Commentary research methodologies, both for generating evidence on quality and for assessing appropriateness based upon that evidence. Future assessments of the role of chiropractic in US health care will inevitably involve political considerations as well as scientific evidence. Whereas chiropractic physicians may have limited control over the former, the profession can exert some control over the latter by guiding the research agenda toward a comprehensive assessment of the benefits of chiropractic care.

Funding sources and potential conflicts of interest Drs Whedon and Davis are both supported by grants from The National Center for Complementary and Alternative Medicine and The Bernard Osher Foundation. Dr Whedon's grant is titled “Utilization and Safety of Chiropractic Care in Older Adults” (5K01AT005092-02). The views expressed herein do not necessarily represent the views of the National Center for Complementary and Alternative Medicine or of the National Institutes of Health. No conflicts of interest were reported for this study.

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Journal of Chiropractic Humanities (2010) 17, 47–54

Original article

The Fountain Head Chiropractic Hospital: the dream that almost came true Barclay W. Bakkum DC, PhD a,⁎, Delores Bakkum Nolan b a b

Associate Professor, Illinois College of Optometry, Chicago, IL 60616 Vice President, Nolan X-Ray Filters, Wanganui, New Zealand

Received 30 July 2010; received in revised form 1 September 2010; accepted 2 September 2010 Key indexing terms: Chiropractic; History; Hospitals

Abstract Objective: The purpose of this article is to relate information about the life of Dr William Ivens and describe the worldwide effort led by him to establish a chiropractic hospital at the Palmer School of Chiropractic. Discussion: Dr William Ivens, a colorful politician and chiropractor from Winnipeg, Canada, was the driving force behind the idea of establishing a chiropractic hospital at the Palmer School of Chiropractic in Davenport, IA, during the late 1930s. With the blessings of Dr BJ Palmer, president of the Palmer School of Chiropractic, Dr Ivens led an aggressive, worldwide campaign to raise the funds necessary to establish what was to be called the Fountain Head Chiropractic Hospital. During the tumultuous years of 1937-1942, this campaign successfully raised the target sum of $50000, thought necessary to create the hospital, but the idea never became a reality. These funds were eventually used to purchase the Clear View Sanitarium, a chiropractic psychiatric facility, in Davenport, IA, in 1952. Conclusion: Dr William Ivens stands as a prime example of a relatively small, but dedicated, number of chiropractors during the mid-20th century who not only believed in, but toiled for, the idea of chiropractic care being given in an in-patient setting. © 2010 National University of Health Sciences.

With these words in 1937, there began a worldwide appeal to establish a chiropractic hospital at the Palmer School of Chiropractic (PSC):

“Does not the reader agree with me that the next great step forward ought to be the establishment at the PSC of a wonderful Chiropractic Hospital, to which patients of all classes, from every nation, could come, and in which they would be nursed back to health under competent Chiropractic services?”1

⁎ Corresponding author. Illinois College of Optometry, 3241 South Michigan Ave, Chicago, IL 60616. Tel.: +1 312 949 7267; fax: +1 312 949 7387. E-mail address: [email protected] (B. W. Bakkum).

The importance of complete chiropractic care, including hospitalization, was understood from the very beginning of the chiropractic profession by its founder, Dr Daniel David Palmer. There were in-patient facilities at the PSC from its inception in

Introduction

1556-3499/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.echu.2010.09.001

48

B. W. Bakkum, D. B. Nolan

the late 1890s to the mid-1920s.2 The idea of a chiropractic hospital at the PSC was reawakened in the mid-1930s. Interestingly, the principal force behind this movement was not Dr Bartlett Joshua Palmer, the charismatic son of DD Palmer and president of the PSC, but Dr William Ivens of Winnipeg, Manitoba, Canada. The purpose of this article is to relate information about the life of Dr Ivens and describe the effort led by him to fulfill his “dream of a Chiropractic Hospital equipped and established as the voluntary goodwill contribution of chiropractors and patients the world over to The PSC The Fountain Head of Chiropractic." 3

William Ivens, MA, BD, DC William “Bill” Ivens (Fig 1) was born in Barford, Warwickshire, England, in 1878.4 He emigrated to Manitoba, Canada, in 1896. After graduating from the University of Manitoba, he became a Methodist minister at the McDougal Church in Winnipeg. Rev Ivens was a well-known social activist and broke with

Fig 2. Drs William Ivens and BJ Palmer, undated (photograph from authors' private collection).

Fig 1. William “Bill” Ivens, MA, BD, DC circa 1939 (photograph from authors' private collection).

the church over his pacifism during World War I. He was ultimately expelled from the Methodist Church for his political views and went on to found the Labour Church. His sermons centered on politics, philosophy, and religion. In 1918, Rev Ivens became editor of the Western Daily News, a labor newspaper. He was arrested and found guilty of seditious conspiracy in 1920 for activities related to his staunch support of the local labor movement during the Winnipeg General Strike of 1919. Ironically, and apparently legally, while serving a 1-year prison sentence, William Ivens ran for and was elected to the Manitoba legislature as a member of the Dominion Labour Party. He was reelected for 2 additional terms in 1922 and 1927. During this time, William Ivens also completed further studies and became a 1926 graduate of the Manitoba School of Chiropractic. 5 As Dr William Ivens, he conducted a successful chiropractic practice out of his home in Winnipeg until the mid-1950s. Dr Ivens lost his seat in the Manitoba Legislature in the 1936 elections and never held public office again. 5

Fountain Head Hospital He tried to remain active in politics, but his influence waned as a younger generation came into power. 4 It is not certain when Dr Ivens became acquainted with Dr BJ Palmer; but by the mid-1930s, the two carried on an extensive correspondence and even friendship that lasted over the next quarter century 6-10 (Fig 2). It was during this time that he came upon the idea of establishing a hospital at the PSC.

Palmer Hospital: the idea The notion of creating a chiropractic hospital at the PSC appears to have originated with Dr Ivens around 1932, but BJ rejected this suggestion at that time. 1 Undaunted, Ivens continued to work behind the scenes. By 1935, he had formulated a detailed plan to make what he called the Fountain Head Chiropractic Hospital. This was to be constructed in conjunction with the BJ Palmer Clinic, the already existing outpatient facility at the PSC.11 Finally, in 1937, Dr BJ Palmer… “… agreed to the suggestion provided he personally be allowed to stand aside, an interested, but inactive, onlooker. Since the proposed hospital would be set up as part of the institution which he personally owns, his proviso is readily understood and appreciated. He has now agreed to set aside the whole second floor of his huge Clinic building just as soon as the proposal sufficiently matures.”3

Throughout the ensuing campaign to create the hospital, BJ Palmer, who understood the political climate of the time, continued to support the idea, but behind the scenes. In a letter to Dr Ivens dated July 1, 1940, he wrote: “I am as vitally interested in the necessity for the hospital as I ever was. It IS needed and badly. But, it does seem to be a case of ‘Be damned if you do, and be damned if you don't.’ If I was outright for it then I was ‘after more money.’ If I didn't say anything and let you folks take the initiative and go ahead, with my silent acquiescence, then B. J. does not really want the hospital, and so on. What to do?”12

Therefore, it appears that Dr Ivens became the leader of the movement to build the hospital with Dr Palmer's blessings and full support. After architectural consultation, it was thought that the space set aside for the hospital could be made into 35 to 40 wards with from 1 to many beds each.3 “When completed the hospital will be composed of four distinct types of wards and service, as follows: 1. Wards for general Chiropractic hospitalization.

49 2. Obstetrical wards where Chiropractic service will prevail. 3. Traumatic wards, where patients accidentally injured will no longer be deprived of Chiropractic service. 4. Service in a separate institution where mental cases can get the finest type of Chiropractic Health Service.”11 There were blueprints that were eventually rendered in 1941, but these appear to have been lost. 13 The average cost for each ward was approximately $1000, and it was thought that another $20 000 would be needed to provide equipment. Therefore, a sum of $50000 would be needed to initiate this project; and this became the goal of an aggressive, worldwide fundraising project led by Dr Ivens.

Fountain Head Chiropractic Hospital: the campaign Dr Ivens made his dream known to the world in an article entitled “A Wonderful Half Century,” which appeared in the December 1937 issue of The Chiropractor. The Chiropractor was a monthly publication of the PSC that, according to its title page, was “A National Magazine Devoted to the Promotion and Perpetuation of Straight Chiropractic.”1 This magazine became the primary method that Ivens used to communicate information about the hospital campaign to the profession, at least that portion of the profession that seemed to be aligned with the Palmer style of chiropractic. From December 1937 through September 1942, Dr Ivens wrote almost monthly articles in The Chiropractor. Throughout this nearly 5-year period, only 5 issues of The Chiropractor did not have an article written by Dr Ivens. In most of these articles, he promoted the campaign to raise funds for the hospital and reported the status of the campaign. Dr Ivens was very idealistic about his idea. After presenting the notion of creating a chiropractic hospital at the PSC, his “thought was that chiropractors everywhere spontaneously and voluntarily unite their forces to create and equip the hospital.…”11 He saw this project as a profession-wide undertaking. In an article in the March 1938 issue of The Chiropractor entitled “Chiropractic Hospital at the ‘PSC’ a Practical Proposal—A Dream that Must Come True,” Dr Ivens appealed to “Chiropractors and Patients the world over” that “(n)ow is the time for us all to make a gesture that will fittingly honor our profession.”3 Not only did he think that there would

50

B. W. Bakkum, D. B. Nolan making. If B.J. and the chiropractic profession had real idealism and had the Science at heart as much as they claim, instead of fighting and back-biting each other in all the many years they could have established something that the whole world would have been proud of. However it isn't to [sic] late yet.”14

Fig 3. Cover of pamphlet that accompanied the announcement of the Fountain Head Chiropractic Hospital Organization at the 1938 PSC Lyceum (from authors' private collection).

be worldwide support for the PSC hospital, but that from it would “be created a world-wide Chiropractic Hospital Consciousness.”11 In this vein, in 1939, he received a letter from a Dr Peter Boike, who at the time was apparently rendering chiropractic services to Mahatma Gandhi in India, which stated: “Now in regards to the hospital plan I am most heartily in favor of the plan. It is 20 years too late in its

On the other hand, Dr Ivens was a practical person and a shrewd businessman. At the PSC Lyceum in August 1938, he unveiled The Fountain Head Chiropractic Hospital Organization 11 (Fig 3). This organization had a World Chiropractic Committee that was composed of local committees in each state, Canadian province, and 11 foreign countries, one of which was Alaska, that were to work out their own methods of raising the necessary contributions. It also created the Fountain Head Chiropractic Hospital Fund Advisory Board that would be in charge of the funds and would work in close cooperation with the PSC. Dr Ivens was the chairman of the Advisory Board; however, it is interesting to note that Dr Palmer was not an official part of the organization at all. The Advisory Board's headquarters offices were in Davenport, IA (location of the PSC). As funds were received, they were “placed with two reliable chartered banks, and auditors appointed to assure that all monies were accurately accounted for,” and “the headquarters office can expend no funds until so instructed by the executive officers, and their joint signatures appended to checks issued.”11 Besides direct appeals, several other fund-raising techniques were used. These included letter writing campaigns, 9,15,16 at least one appeal over WOC, the radio station in Davenport, IA, owned by BJ Palmer,15 and explanatory literature available to chiropractors to put in their offices in order to generate donations from patients. 11 A novel notion was the use of money (dime) banks in the shape of the clinic building at the PSC (Fig 4). It should be noted that the banks were modeled on a building with 3 stories, but the BJ Palmer Clinic building actually had only 2 stories. This seems to be a reflection of the unbridled optimism that Dr Ivens had for the project. Near the beginning of the campaign, he wrote that “(o)nce this institution is established I forsee a rapid expansion. It may well be that shortly another floor will have to be added to find accommodation for the many patients who may throng from all parts of the world.”3 Another innovative idea was that of ward sponsorship. It was suggested that donations of $1000 be raised by individuals, states, companies, and organizations to sponsor a hospital ward.11 A Children's Ward was suggested in a letter from Dr Ivens to Dr Palmer.17 The

Fountain Head Hospital

51

Fig 4. Dime bank used as part of the campaign to raise funds for the Fountain Head Chiropractic Hospital (photograph from authors' private collection).

most popular ward was the Mabel Palmer Ward. Dr Mabel Palmer, BJ's wife, was well known in the chiropractic profession and especially at the PSC where she taught anatomy, wrote an anatomical textbook, and was a popular figure on campus. This ward was oversold, as a letter-writing campaign raised $2000 from 200 lady chiropractors and chiropractic wives in just 2 months.16 The first progress report of how the campaign was going was in a May 1939 article in The Chiropractor, which stated that the Chiropractic Hospital Fund had $10296.16 cash on hand plus $13934.57 in pledges, for a total of $24229.73.18 This represented 48% of the goal of $50000. In March 1940, cash on hand ($26991.73) and pledges ($16002.00) had reached $42993.73.19 By August that same year, Ivens reported a total of $45 122.72 (cash, $31 456.01; pledges, $13666.71).20 In September 1940, it was triumphantly announced in The Chiropractor article entitled “Chiropractic Hospital Fund Goes Over the Top” that the campaign had a total of $50349.00.21 Unfortunately, only $34 769.03 was cash on hand. There were $15589.87 in pledges that were still outstanding.

Throughout 1941 and most of 1942, Dr Ivens' articles in The Chiropractor had a different feel. These articles were mostly about social or political issues. Only a few of them mentioned the hospital campaign in passing. The exception was the November 1941 article where the Bakkum Chiropractic Hospital in Waukon, IA, 22 was touted as a prime example of chiropractic hospitalization. 13 The article even included pictures. It was also noted that the hospital campaign had $46552.92 on hand. The only other report on the hospital campaign during this period came in April 1942.23 Ivens' article noted that the hospital campaign lacked only $1239.96 from reaching its stated goal of $50 000. Dr Ivens and Drs Roy and Jessie Bakkum, who owned the Bakkum Chiropractic Hospital, were good friends. Dr Roy was the chairman of the Iowa committee in the Fountain Head organization. 11 In 1939, Drs Bakkum visited Dr Ivens in Winnipeg, along with other interested parties from Canada, to meet about the hospital. 24-27 This meeting happened to occur when the King and Queen of England were

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B. W. Bakkum, D. B. Nolan

Fig 5. Clock and accompanying statues from William Ivens that were presented to BJ Palmer by Roy and Jessie Bakkum for the use in the Fountain Head Chiropractic Hospital displayed on the main fireplace mantle in BJ Palmer's mansion in Davenport, IA (photograph from authors' private collection).

in Winnipeg; and because Drs Ivens still had some political connections, he and Jessie attended a speech given by the King. The Drs Bakkum brought back a clock with 2 accompanying statues from Dr Ivens that was presented to Dr Palmer for placement in the hospital. The clock and statues are still on display on the mantle in the BJ Palmer mansion in Davenport, IA (Fig 5). Also from 1940 to 1942, Milton Ivens, MD, who was the son of William Ivens, worked as the resident medical physician and lived at the Bakkum Chiropractic Hospital. 22 In September 1942, Dr Ivens wrote what was to be his last article in The Chiropractor for nearly a decade. 28 Entitled “War Makes Chiropractic Hospital Imperative,” it represented the official announcement that the hospital campaign was ceasing. The final balance sheet showed $51061.67 cash on hand and $10510.54 in outstanding pledges, for a grand total of $61572.21. A roll call of states was included that gave the totals of funds from each state. Not too surprisingly, Iowa had the biggest total with pledges of $12 681.35, of which $12 091.55 had been received as cash. Therefore, the hospital campaign did reach its stated goal of raising $50000; but unfortunately, the Fountain Head Chiropractic Hospital was never realized.

Outcomes Even though $50000 was the goal for the initial fundraising campaign, this amount was seen as only a beginning. Hospitals are expensive propositions, and the people involved with this campaign knew this. In a 1940 letter from Dr Mabel Palmer to Dr Ivens, she wrote: “In building any kind of structure, it always runs beyond the first amount that is laid down, and in building a hospital and having it in keeping with B.J.'s Clinic, will run in excess of $50,000.… I am facing this hospital in cold figures, and I know that after the $50,000 is raised it will take more to complete it; and I know that neither B.J. nor I will plunge ourselves into such indebtedness as we have in the past—much as I see that the hospital is needed badly.… There is not anything I would like to see in these few years that we have ahead of us, to complete the picture here at the Fountain Head, more than to have a beautiful hospital.”29

The timing of the notion of creating a hospital at the PSC was not optimal given the larger world picture. With the fund-raising campaign starting during the depths of the Great Depression, donations were

Fountain Head Hospital relatively difficult to elicit from people who were trying to make financial ends meet. Furthermore, the goal of raising the $50000 was realized during the early portion of America's involvement in World War II. With the uncertainty of the times, it is not surprising that there was no rush to start construction. With the official end of the hospital campaign in September 1942, Dr Ivens appears to have started playing a smaller role in the life of the PSC. It is known that he worked at collecting pledges for the hospital as late as 1948.30 Even so, his hope for a hospital at the PSC was still alive. In 1948, he wrote to Dr Palmer: “The future holds great possibility and will make heavy demands along chiropractic hospitalization lines. May the PSC play its full part when the time comes.”10

BJ had not given up on the idea either. After Dr Mabel Palmer died in 1949, Dr BJ Palmer wrote a general letter of appreciation to his colleagues and friends. He concludes the letter: “Six suggestions have been received re a Memorial to Mabel. What could be more appropriate than THE MABEL PALMER MEMORIAL HOSPITAL, a fund now existing for that purpose?”31

The funds raised for the hospital were “placed in government bonds”32 and held in Davenport until 1951. At this point, an opportunity arose for the money to be used toward fulfilling at least part of Dr Ivens' original dream. The Clear View Sanitarium, a chiropractic mental hospital, had been founded in Davenport in 1926.33 When its owners retired in 1951, they wished “to insure the continuation of the sanitarium as a Chiropractic institution, converted this desire into reality by offering the institution to the Fountain Head Hospital Committee.”33 The board accepted the offer, and “(o)n October 13th, the purchasing committee of the Fountain Head Hospital Fund deeded Clear View Sanitarium to the Palmer School of Chiropractic.”33 This represented a de facto end for the Fountain Head Hospital becoming a reality, since the Clear View Sanitarium continued to function under its original name until it was closed in 1961.33 This mental health facility was the only part of the original plan that was actually achieved. By this time, Dr Ivens was no longer chairman of nor even sat on the Fountain Head Chiropractic Hospital Fund Advisory Board. It is not clear why this change occurred. At the time of the purchase of Clear View, the Board was chaired by Tena S Murphy, DC.

53 Dr Murphy had been an important part of the hospital project from the very beginning. She was the secretary of the Fountain Head Chiropractic Hospital Fund Advisory Board when it was created in 193811 and had also been involved in the WOC radio campaign.9 It appears that Dr Murphy had become the chair of the board shortly before the purchase of Clear View and that Dr Ivens was glad at this turn of events. In a letter to Drs Roy and Jessie Bakkum dated September 5, 1951, Dr Ivens stated that he had received a letter from Dr Murphy the day before in which she informed him that there had been an election of officers for the committee and that she “is now the new President of the group. That is most fitting isn't it?”34 Even though Dr Ivens was not on the Board, Dr Palmer still valued Dr Ivens' opinion and asked for it relative to the purchase of Clear View. Dr Ivens related to the Drs Bakkum that “(h)e [Dr Palmer] phoned me three times and wired me twice, so my advice was sought thereon.”34 In this same letter, Dr Ivens seemed pleased that the money for his vision was used as it was, although he still had hoped that this was only a beginning: “Yes, we are all glad that at long last the money we so laboriously raised a decade ago has now been invested in ‘Clearview Sanatorium’ [sic]. The property is good; the location ideal; and my hope is that presently the institution can be expanded into a general hospital as well as a mental one.”34

Dr Palmer had also not given up on the idea of a true hospital at the PSC. With the coming acquisition of the Clear View Sanitarium in 1951, “Dr. B.J. Palmer, president of The Palmer School, who announced the anticipated change at the annual Lyceum in August, indicated that Clear View would stand as the first unit in a hospital plan to include other buildings and facilities as soon as funds and available material permitted.”33

After the Fountain Head Hospital Fund had been spent to acquire Clear View, Dr Ivens appears to have faded further out of the picture. At the time of the purchase of Clear View, he sent an airmail letter to Dr Palmer asking whether or not he and Ralph Evans (editor of The Chiropractor) wanted him to write an article for that publication on how the hospital funds were used for that purpose. 34 Apparently, he was not taken up on the offer because he had only 2 more articles that appeared in The Chiropractor, both in 1952 and both concerning social issues: the Cold War 35 and world food supplies. 36

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B. W. Bakkum, D. B. Nolan

Although he was not an active part of events at the PSC any more, Dr Ivens still did not want to be forgotten. In a letter to Drs Roy and Jessie Bakkum sent when they were preparing to go to the PSC Lyceum in 1954, Dr Ivens wrote: “If you see Tena Murphy please say a hearty ‘Hello’ for me. She holds a warm place in my esteem. Also, if you chat with B.J. tell him that often he is in my thoughts, and that I am happy that the hospital is now part of the PSC set up. That was a fortunate purchase for sure.”37

Because of failing health, Dr Ivens spent his last years with his son, Milton Ivens, in California. He died in Chula Vista, CA, in 1958, just before his 80th birthday.4

Conclusion Dr William Ivens had a dream that chiropractic hospitals would be a worldwide phenomenon and that the flagship institution would be the Fountain Head Chiropractic Hospital at the PSC in Davenport, IA. During some of the most challenging years of the 20th century, he worked tirelessly to try to make this dream come true. Even after the campaign to raise funds for the hospital did not fulfill this dream in the way he envisioned, Dr Ivens did not let go of the idea. He held on, until the end of his days, to the belief that the world needs chiropractic care in a hospital setting. Because of the political climate during Dr Ivens' era, the only way for chiropractic in-patient care to become a reality was for the chiropractic profession to build its own facilities. This did not prove to be cost effective. More recently, through the diligent work of other leaders in the chiropractic profession, a few doctors of chiropractic have gained the necessary privileges to offer their services in conventional inpatient facilities, eg Veterans' Administration hospitals. It may well be that Dr Ivens' notion of chiropractic care being available to hospitalized patients may still become a reality, although not in the way he envisioned, as separate facilities, but rather by doctors of chiropractic being added to the health care teams managing patients in mainstream hospitals.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. Ivens W. A wonderful half century. The Chiropractor 1937; 33(12):11-2. 2. Gibbons RW. Chiropractors as interns, residents and staff: the hospital experience. Chiropr Hist 1983;3:51-7. 3. Ivens W. Chiropractic hospital at the “PSC” a practical proposal—a dream that must come true. The Chiropractor 1938;34(3):9. 4. Gutkin H, Gutkin M. Profiles in dissent: the shaping of radical thought in the Canadian west. Edmonton, Alberta: NeWest; 1997. p. 51-92. 5. Butt M, “To each according to his need, and from each according to his ability. Why cannot the world see this?”: the politics of William Ivens, 1916-1936. MA thesis: University of Winnipeg, 1993. 6. Palmer BJ, letter to W Ivens, 5 April, 1938. 7. Palmer BJ, letter to W Ivens, 18 July, 1938. 8. Palmer BJ, letter to W Ivens, 23 July, 1938. 9. Ivens W, letter to BJ, Mabel, and Dave Palmer, 25 December, 1938. 10. Ivens W, letter to BJ Palmer, 6 June, 1948. 11. Ivens W, The Fountain Head Chiropractic Hospital Organization Rapidly Taking Shape. unpublished pamphlet, 1938. 12. Palmer BJ, letter to W Ivens, 1 July, 1940. 13. Ivens W. Blueprints make history. The Chiropractor 1941;37 (11):15. 14. Boike P, letter to W Ivens, 16 January, 1939. 15. Ivens W, letter to BJ Palmer, 29 December, 1938. 16. Ivens W, letter to Drs Biggs, 23 February, 1940. 17. Ivens W, letter to BJ Palmer, 24 December, 1938. 18. Ivens W. Chiropractic hospital fund on home stretch. The Chiropractor 1939;35(5):17-8. 19. Ivens. Britain pays tribute to naval heroes. The Chiropractor 1940;36(3):13-4. 20. Ivens W. Believe it or not. The Chiropractor 1940;36(8):14-5. 21. Ivens W. Chiropractic hospital fund goes over the top. The Chiropractor 1940;36(9):16-7. 22. Bakkum BW, Green BN. Chiropractic hospitals in America: a case study of the Bakkum hospital (1936-1950). J Manipulative Physiol Ther 2001;24(1):34-43. 23. Ivens W. The faith and fire within you. The Chiropractor 1942;38(4):20. 24. Bakkum RC, letter to Bakkum family, 24 May, 1939. 25. Bakkum JH, letter to Bakkum family, 26 May, 1939. 26. Bakkum RC, letter to WC and MI Bakkum, 30 May, 1939. 27. Bakkum RC, letter to WC and MI Bakkum, 4 June, 1939. 28. Ivens W. War makes chiropractic hospital imperative. The Chiropractor 1942;38(9):12-3. 29. Palmer M, letter to W Ivens, 23 July, 1940. 30. Palmer BJ, letter to W Ivens, 28 May, 1948. 31. Palmer BJ, letter, 16 April, 1949. 32. Quigley WH. Pioneering mental health: institutional psychiatric care in chiropractic. Chiropractic History 1983;3(1):69-73. 33. Hynes RJR. Chiropractic's foray into mental health. Chiropractic History 2008;28(2):61-70. 34. Ivens W, letter to RC and JH Bakkum, 5 September, 1951. 35. Ivens W. What is the inner meaning of a cold war? The Chiropractor 1952;48(1):9. 36. Ivens W. World population and food supplies. The Chiropractor 1952;48(2):4. 37. Ivens W, letter to RC and JH Bakkum, 12 August, 1954.